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2014 Edition Paramedic

Clinical Practice Guidelines

CLINICAL PRACTICE GUIDELINES - 2014 Edition

Practitioner Paramedic

1 Clinical Practice Guidelines

CLINICAL PRACTICE GUIDELINES - 2014 Edition

PHECC Clinical Practice Guidelines First Edition 2001 Second Edition 2004 Third Edition 2009 Third Edition Version 2 2011 Fourth Edition April 2012 Fifth Edition July 2014

Published by:

Pre-Hospital Emergency Care Council Abbey Moat House, Abbey Street, Naas, Co Kildare, Ireland Phone: + 353 (0)45 882042 Fax: + 353 (0)45 882089 Email: [email protected] Web: www.phecc.ie

ISBN 978-0-9571028-8-0 © Pre-Hospital Emergency Care Council 2014

Permission is hereby granted to redistribute this document, in whole or part, for educational, non-commercial purposes providing that the content is not altered and that the Pre-Hospital Emergency Care Council (PHECC) is appropriately credited for the work. Written permission from PHECC is required for all other uses. Please contact the author: [email protected]

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CLINICAL PRACTICE GUIDELINES - 2014 Edition

TABLE OF CONTENTS

FOREWORD ...... 4 ACCEPTED ABBREVIATIONS ...... 5 ACKNOWLEDGEMENTS ...... 7 INTRODUCTION ...... 9 IMPLEMENTATION AND USE OF CLINICAL PRACTICE GUIDELINES ...... 10

CLINICAL PRACTICE GUIDELINES

INDEX ...... 12 KEY/CODES EXPLANATION ...... 14 SECTION 1 CARE PRINCIPLES ...... 15 SECTION 2 PATIENT ASSESSMENT ...... 16 SECTION 3 RESPIRATORY EMERGENCIES ...... 21 SECTION 4 MEDICAL EMERGENCIES ...... 26 SECTION 5 OBSTETRIC EMERGENCIES ...... 53 SECTION 6 TRAUMA ...... 59 SECTION 7 PAEDIATRIC EMERGENCIES ...... 70 SECTION 8 PRE-HOSPITAL EMERGENCY CARE OPERATIONS ...... 95

SECTION 9 TREAT & REFERRAL ...... 100

Appendix 1 - Medication Formulary ...... 103 Appendix 2 – Medications & Skills Matrix ...... 129 Appendix 3 – Critical Incident Stress Management ...... 136 Appendix 4 – CPG Updates for Paramedics ...... 138 Appendix 5 – Pre-Hospital Defibrillation Position Paper ...... 146

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FOREWORD

The role of the Pre-Hospital Emergency Care Council (PHECC) is to protect the public by independently specifying, reviewing, maintaining and monitoring standards of excellence for the delivery of quality pre-hospital emergency care for people in Ireland. The contents of this clinical publication are fundamental to how we achieve this goal. Clinical Practice Guidelines have been developed for responders and practitioners to aid them in providing world-class pre-hospital emergency care to people in Ireland. I would like to thank the members of the Medical Advisory Committee, chaired by Dr Mick Molloy for their efforts and expertise in developing these guidelines. The council acknowledge the work of the PHECC Executive in researching and compiling these Guidelines, in particular Mr Brian Power, Programme Development Officer. I also commend the many responders and practitioners whose ongoing feedback has led to the improvement and creation of many of the Guidelines herein. The publication of these Guidelines builds on the legacy of previous publications and marks yet another important milestone in the development of care delivered by responders and practitioners throughout Ireland. Despite the difficulties faced by responders and licensed service providers, I am proud that they continue to develop their skills and knowledge to provide safer and more effective patient care.

______Mr Tom Mooney, Chair, Pre-Hospital Emergency Care Council

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ACCEPTED ABBREVIATIONS

Accepted abbreviations Advanced Paramedic ...... AP Advanced Life Support ...... ALS Airway, Breathing & Circulation ...... ABC All Terrain Vehicle ...... ATV Altered Level of Consciousness ...... ALoC Automated External Defibrillator ...... AED Bag Valve Mask ...... BVM Basic Life Support ...... BLS Blood Glucose ...... BG Blood Pressure ...... BP Basic Tactical Emergency Care ...... BTEC

Carbon Dioxide ...... CO2 Cardiopulmonary Resuscitation ...... CPR Cervical Spine ...... C-spine Chronic Obstructive Pulmonary Disease ...... COPD Clinical Practice Guideline ...... CPG Degree ...... o Degrees Centigrade ...... oC

Dextrose 10% in water ...... D10W Drop (gutta) ...... gtt Electrocardiogram ...... ECG Emergency Department ...... ED Emergency Medical Technician ...... EMT Endotracheal Tube ...... ETT Foreign Body Airway Obstruction ...... FBAO Fracture ...... # General Practitioner ...... GP Glasgow Coma Scale ...... GCS Gram ...... g Milligram ...... mg Millilitre ...... mL

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ACCEPTED ABBREVIATIONS (contd)

Millimole ...... mmol Minute ...... min Modified Early Warning Score ...... MEWS Motor Vehicle Collision ...... MVC Myocardial Infarction ...... MI Nasopharyngeal airway ...... NPA Milliequivalent ...... mEq Millimetres of mercury ...... mmHg Nebulised ...... NEB Negative decadic logarithm of the H+ ion concentration ...... pH Orally (per os) ...... PO Oropharyngeal airway ...... OPA

Oxygen ...... O2 Paramedic ...... P Peak Expiratory Flow ...... PEF Per rectum ...... PR Percutaneous Coronary Intervention ...... PCI Personal Protective Equipment ...... PPE Pulseless Electrical Activity ...... PEA Respiration rate ...... RR Return of Spontaneous Circulation ...... ROSC Revised Trauma Score ...... RTS

Saturation of arterial oxygen ...... SpO2 ST Elevation Myocardial Infarction ...... STEMI Subcutaneous ...... SC Sublingual ...... SL Systolic Blood Pressure ...... SBP . Therefore ...... Total body surface area ...... TBSA Ventricular Fibrillation...... VF Ventricular Tachycardia...... VT When necessary (pro re nata) ...... prn

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ACKNOWLEDGEMENTS

The process of developing CPGs has been long and detailed. Mr Thomas Keane, Paramedic, Member of Council The quality of the finished product is due to the painstaking work of many people, who through their expertise and review Mr Shane Knox, Education Manager, National Ambulance of the literature, ensured a world-class publication. Service College Col Gerard Kerr, Director, the Defence Forces Medical Corps PROJECT LEADER & EDITOR Mr Declan Lonergan, Advanced Paramedic, Education & Competency Assurance Manager, HSE National Mr Brian Power, Programme Development Officer, PHECC. Ambulance Service Mr Seamus McAllister, Divisional Training Officer, Northern INITIAL CLINICAL REVIEW Ireland Ambulance Service Dr David McManus, Medical Director, Northern Ireland Dr Geoff King, Director, PHECC. Ambulance Service Ms Pauline Dempsey, Programme Development Officer, Dr David Menzies, Consultant in Emergency Medicine, Clinical PHECC. Lead, Emergency Medical Science, University College Ms Jacqueline Egan, Programme Development Officer, PHECC. Dublin Mr Shane Mooney, Advanced Paramedic, Chair of Quality and Safety Committee MEDICAL ADVISORY COMMITTEE Mr Joseph Mooney, Emergency Medical Technician, Dr Mick Molloy, (Chair) Consultant in Emergency Medicine Representative from the PHECC register Dr Niamh Collins, (Vice Chair) Consultant in Emergency Mr David O’Connor, Advanced Paramedic, representative from Medicine, Connolly Hospital Blanchardstown the PHECC register Prof Gerard Bury, Professor of General Practice, University Dr Peter O’Connor, Consultant in Emergency Medicine, College Dublin Medical Advisor Dublin Fire Brigade Dr Seamus Clarke, General Practitioner, representing the Irish Mr Cathal O’Donnell, Consultant in Emergency Medicine, College of General Practitioners Medical Director, HSE National Ambulance Service Mr Jack Collins, Emergency Medical Technician, Mr Kenneth O’Dwyer, Advanced Paramedic, representative Representative from the PHECC register from the PHECC register Prof Stephen Cusack, Consultant in Emergency Medicine, Mr Martin O’Reilly, Advanced Paramedic, District Officer Cork University Hospital Dublin Fire Brigade A/Prof Conor Deasy, Consultant in Emergency Medicine, Mr Rory Prevett, Paramedic, representative from the PHECC Cork University Hospital, Deputy Medical Director HSE register National Ambulance Service Dr Neil Reddy, Medical Director, Code Blue Mr Michael Dineen, Paramedic, Vice Chair of Council Mr Derek Rooney, Paramedic, representative from the PHECC Mr David Hennelly, Advanced Paramedic, Clinical register Development Manager, National Ambulance Service Ms Valerie Small, Advanced Nurse Practitioner, Chair of Mr Macartan Hughes, Advanced Paramedic, Head of Education and Standards Committee. Education & Competency Assurance, HSE National Ambulance Service Dr Sean Walsh, Consultant in Paediatric Emergency Medicine, Our Lady’s Hospital for Sick Children, Crumlin Mr David Irwin, Advanced Paramedic, representative from the Irish College of Paramedics

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ACKNOWLEDGEMENTS

EXTERNAL CONTRIBUTORS Ms Barbara Shinners, Emergency Medical Technician Ms Diane Brady, CNM II, Delivery Suite, Castlebar Hospital. Dr Dermott Smith, Consultant Endocrinologist Mr Ray Brady, Advanced Paramedic Dr Alan Watts, Register in Emergency Medicine Mr Joseph Browne, Advanced Paramedic Prof Peter Weedle, Adjunct Prof of Clinical Pharmacy, National University of Ireland, Cork. Dr Ronan Collins, Director of Stroke Services, Age Related Health Care, Adelaide & Meath Hospital, Tallaght. Mr Brendan Whelan, Advanced Paramedic Mr Denis Daly, Advanced Paramedic Mr Jonathan Daly, Emergency Medical Technician SPECIAL THANKS Dr Zelie Gaffney Daly, General Practitioner HSE National Clinical Programme for Acute Coronary Syndrome Prof Kieran Daly, Consultant Cardiologist, University Hospital HSE National Asthma Programme Galway HSE National Diabetes Programme Mr Mark Dixon, Advanced Paramedic HSE National Clinical Programme for Emergency Medicine Dr Colin Doherty, Neurology Consultant HSE National Clinical Programme for Epilepsy

Mr Michael Donnellan, Advanced Paramedic HSE National Clinical Programme for Paediatrics and Dr John Dowling, General Practitioner, Donegal Neonatology Mr Damien Gaumont, Advanced Paramedic Dr Una Geary, Consultant in Emergency Medicine A special thanks to all the PHECC team who were involved in this project. In particular Ms Deirdre Borland for her dedication Dr David Janes, General Practitioner in bringing this project to fruition. Mr Lawrence Kenna, Advanced Paramedic Mr Paul Lambert, Advanced Paramedic EXTERNAL CLINICAL PROOFREADING Dr George Little, Consultant in Emergency Medicine Mr Michael Murphy, Paramedic Mr Christy Lynch, Advanced Paramedic Mr Austin Florish, Paramedic Dr Pat Manning, Respiratory Consultant Dr Adrian Murphy, Specialist Register in Emergency Medicine Dr Regina McQuillan, Palliative Care Consultant, St Francis Hospice, Raheney Prof. Alf Nickolson, Consultant Paediatrician Dr Susan O’Connell, Consultant Paediatrician Mr Paul O’Driscoll, Advanced Paramedic Ms Helen O’Shaughnessy, Advanced Paramedic Mr Tom O’Shaughnessy, Advanced Paramedic Dr Michael Power, Consultant Anaesthetist Mr Colin Pugh, Paramedic Mr Kevin Reddington, Advanced Paramedic 8 Clinical Practice Guidelines

INTRODUCTION

Clinical Practice Guidelines for pre-hospital care are under constant review as practices change, new therapies and medications are introduced, and as more pre-hospital clinical pathways are introduced such as Code STEMI and code stroke which are both leading to significant improved outcomes for patients. A measure of how far the process has developed can be gained from comparing the 29 Standard Operating Procedures for pre-hospital care in existence prior to the inception of the Pre-Hospital Emergency Care Council and the now more than 319 guidelines and growing. The 2014 guidelines include such new developments as the use of intranasal fentanyl for advanced paramedics and harness induced suspension trauma for both practitioners and responders. Clinical Practice Guidelines recognise that practitioners and responders provide care to the same patients but to different skill levels and utilising additional pharmaceutical interventions depending on the practitioner level. This edition of the guidelines has introduced some new concepts such as the basic tactical emergency care standard at EFR and EMT level for appropriately employed individuals. As ever feedback on the guidelines from end users or interested parties is always welcomed and may be directed to the Director of PHECC or the Medical Advisory Committee who review each and every one of the guidelines before they are approved by the Council.

______Dr Mick Molloy, Chair, Medical Advisory Committee.

Feedback on the CPGs may be given through the centre for Pre-hospital Research www.ul.ie/cpr/forum

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IMPLEMENTATION

Clinical Practice Guidelines (CPGs) and the practitioner CPGs are guidelines for best practice and are not intended as a substitute for good clinical judgment. Unusual patient presentations make it impossible to develop a CPG to match every possible clinical situation. The practitioner decides if a CPG should be applied based on patient assessment and the clinical impression. The practitioner must work in the best interest of the patient within the scope of practice for his/her clinical level on the PHECC Register. Consultation with fellow practitioners and or medical practitioners in challenging clinical situations is strongly advised.

The CPGs herein may be implemented provided: 1 The practitioner is in good standing on the PHECC Practitioner’s Register. 2 The practitioner is acting on behalf of a licensed CPG provider (paid or voluntary).

3 The practitioner is privileged by the licensed CPG provider on whose behalf he/she is acting to implement the specific CPG. 4 The practitioner has received training on – and is competent in – the skills and medications specified in the CPG being utilised.

The medication dose specified on the relevant CPG shall be the definitive dose in relation to practitioner administration of medications. The principle of titrating the dose to the desired effect shall be applied. The onus rests on the practitioner to ensure that he/she is using the latest versions of CPGs which are available on the PHECC website www.phecc.ie

Definitions

Adult A patient of 16 years or greater, unless specified on the CPG.

Child A patient between 1 and less than or equal to (≤) 15 years old, unless specified on the CPG

Infant A patient between 4 weeks and less than 1 year old, unless specified on the CPG

Neonate A patient less than 4 weeks old, unless specified on the CPG

Paediatric patient Any child, infant or neonate

CPGs and the pre-hospital emergency care team The aim of pre-hospital emergency care is to provide a comprehensive and coordinated approach to patient care management, thus providing each patient with the most appropriate care in the most efficient time frame. In Ireland today, the provision of emergency care comes from a range of disciplines and includes responders (Cardiac First Responders, First Aid Responders and Emergency First Responders) and practitioners (Emergency Medical Technicians, Paramedics, Advanced Paramedics, Nurses and Doctors) from the statutory, private, auxiliary and voluntary services.

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IMPLEMENTATION

CPGs set a consistent standard of clinical practice within the field of pre-hospital emergency care. By reinforcing the role of the practitioner, in the continuum of patient care, the chain of survival and the golden hour are supported in medical and traumatic emergencies respectively. CPGs guide the practitioner in presenting to the acute hospital a patient who has been supported in the very early phase of injury/illness and in whom the danger of deterioration has lessened by early appropriate clinical care interventions. CPGs presume no intervention has been applied, nor medication administered, prior to the arrival of the practitioner. In the event of another practitioner or responder initiating care during an acute episode, the practitioner must be cognisant of interventions applied and medication doses already administered and act accordingly. In this care continuum, the duty of care is shared among all responders/practitioners of whom each is accountable for his/her own actions. The most qualified responder/practitioner on the scene shall take the role of clinical leader. Explicit handover between responders/practitioners is essential and will eliminate confusion regarding the responsibility for care. In the absence of a more qualified practitioner, the practitioner providing care during transport shall be designated the clinical leader as soon as practical.

Emergency Medical Technician - Basic Tactical Emergency Care (EMT-BTEC) EMT-BTEC certifies registered EMTs with additional knowledge and skill set for providing pre-hospital emergency care in hostile or austere environments. EMT-BTEC training is restricted to EMTs who have the potential to provide emergency care in hostile or austere environments and who are working or volunteering on behalf of a Licensed CPG Provider with specific approval for BTEC provision.

Emergency First Response - Basic Tactical Emergency Care (EFR-BTEC) EFR-BTEC is a new education and training standard published in 2014. Persons certified at EFR-BTEC learn EFR and the additional knowledge and skill set for providing pre-hospital emergency care in hostile or austere environments. Entry to this course is restricted to people who have the potential to provide emergency first response in hostile or austere environments and who are working or volunteering on behalf of a Licensed CPG Provider with specific approval for BTEC provision.

First Aid Response First Aid Response (FAR) is a new education and training standard published in 2014. This standard offers training and certification to individuals and groups who require a first aid skill set including cardiac first response. This standard is designed to meet basic first aid and basic life support (BLS) requirements that a certified person, known as a “First Aid Responder”, may encounter in their normal daily activities.

Defibrillation Policy The Medical Advisory Committee has recommended the following pre-hospital defibrillation policy; • Advanced Paramedics should use manual defibrillation for all age groups. • Paramedics may consider use of manual defibrillation for all age groups. • EMTs and responders shall use AED mode for all age groups.

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INDEX PARAMEDIC CPGs

SECTION 1 CARE PRINCIPLES ...... 15 SECTION 2 PATIENT ASSESSMENT ...... 16 Primary Survey Medical – Adult ...... 16 Primary Survey Trauma – Adult ...... 17 Secondary Survey Medical – Adult ...... 18 Secondary Survey Trauma – Adult ...... 19 Pain Management – Adult ...... 20 SECTION 3 RESPIRATORY EMERGENCIES ...... 21 Advanced Airway Management – Adult ...... 21 Inadequate Ventilations – Adult ...... 22 Exacerbation of COPD ...... 23 Asthma - Adult ...... 24 Acute Pulmonary Oedema - Adult ...... 25 SECTION 4 MEDICAL EMERGENCIES ...... 26 Basic Life Support – Adult ...... 26 Foreign Body Airway Obstruction – Adult ...... 27 VF or Pulseless VT – Adult ...... 28 Asystole – Adult ...... 29 Asystole – Decision Tree ...... 30 Pulseless Electrical Activity – Adult ...... 31 Post-Resuscitation Care – Adult ...... 32 End of Life - DNR ...... 33 Recognition of Death – Resuscitation not Indicated ...... 34 Acute Coronary Syndrome ...... 35 Symptomatic Bradycardia – Adult ...... 36 Tachycardia - Adult ...... 37 Adrenial Insufficiency - Adult ...... 38 Altered Level of Consciousness – Adult ...... 39 Allergic Reaction/Anaphylaxis – Adult ...... 40 Decompression Illness (DCI) ...... 41 Epistaxis ...... 42 Glycaemic Emergency – Adult ...... 43 Hypothermia ...... 44 Poisons – Adult ...... 45 Seizure/Convulsion – Adult ...... 46 Sepsis – Adult ...... 47 Shock from Blood Loss (non-trauma) – Adult ...... 48 Sickle Cell Crisis - Adult ...... 49 Stroke ...... 50 Mental Health Emergency ...... 51 Behavioural Emergency ...... 52 SECTION 5 OBSTETRIC EMERGENCIES ...... 53 Pre-Hospital Emergency Childbirth ...... 53 Basic and Advanced Life Support – Neonate ...... 54 Haemorrhage in Pregnancy Prior to Delivery ...... 55 Postpartum Haemorrhage ...... 56 Umbilical Cord Complications ...... 57 Breech Birth ...... 58

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INDEX PARAMEDIC CPGs

SECTION 6 TRAUMA ...... 59 Burns – Adult ...... 59 Crush Injury ...... 60 External Haemorrhage – Adult ...... 61 Harness Induced Suspension Trauma ...... 62 Head Injury – Adult ...... 63 Heat-Related Emergency ...... 64 Limb Injury – Adult ...... 65 Shock from Blood Loss (trauma)– Adult ...... 66 Spinal Immobilisation – Adult ...... 67 Submersion Incident ...... 68 Traumatic Cardiac Arrest – Adult ...... 69 SECTION 7 PAEDIATRIC EMERGENCIES ...... 70 Primary Survey Medical – Paediatric ...... 70 Primary Survey Trauma – Paediatric ...... 71 Secondary Survey – Paediatric ...... 72 Pain Management – Paediatric ...... 73 Advanced Airway Management – Paediatric ≥ 8 ...... 74 Inadequate Ventilations – Paediatric ...... 75 Asthma - Paediatric ...... 76 Stridor – Paediatric ...... 77 Basic Life Support – Paediatric ...... 78 Foreign Body Airway Obstruction – Paediatric ...... 79 VF or Pulseless VT – Paediatric ...... 80 Asystole/PEA – Paediatric ...... 81 Symptomatic Bradycardia – Paediatric ...... 82 Post Resuscitation Care - Paediatric ...... 83 Adrenial Insufficiency - Paediatric ...... 84 Allergic Reaction/Anaphylaxis – Paediatric ...... 85 Glycaemic Emergency – Paediatric ...... 86 Seizure/Convulsion – Paediatric ...... 87 Septic Shock – Paediatric ...... 88 Pyrexia - Paediatric ...... 89 Sickle Cell Crisis - Paediatric ...... 90 External Haemorrhage – Paediatric ...... 91 Shock from Blood Loss – Paediatric ...... 92 Spinal Immobilisation – Paediatric ...... 93 Burns – Paediatric ...... 94 SECTION 8 PRE-HOSPITAL EMERGENCY CARE OPERATIONS ...... 95 Major Emergency – First Practitioners on site ...... 95 Major Emergency – Operational Control ...... 96 Triage Sieve ...... 97 Triage Sort ...... 98 Conducted Electrical Weapon (Taser) ...... 99 SECTION 9 TREAT & REFERRAL ...... 100 Clinical Care Pathway Decision - T & R ...... 100 Hypoglycaemia - T & R ...... 101 Isolated Seizure - T & R ...... 102

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CLINICAL PRACTICE GUIDELINES for PARAMEDICClinical Practice Guidelines for (CODES EXPLANATION) Paramedic Codes explanation Emergency Medical Technician An EMT who has completed Basic Tactical EMT EMT (Level 4) for which the CPG pertains Emergency Care training and has been BTEC privileged to operate in adverse conditions Paramedic A parallel process P (Level 5) for which the CPG pertains Which may be carried out in parallel Advanced Paramedic with other sequence steps AP (Level 6) for which the CPG pertains A cyclical process in which a number Medical Practitioner of sequence steps are completed MP (Level 7) for which the CPG pertains P Paramedic or lower clinical levels not Sequence step A sequence (skill) to be performed permitted this route

Mandatory A mandatory sequence (skill) to be performed Transport to an appropriate medical sequence step facility and maintain treatment en-route

A decision process If no ALS available Transport to an appropriate medical The Practitioner must follow one route facility and maintain treatment en-route, if having contacted Ambulance Control Given the clinical presentation Consider treatment there is no ALS available options consider the treatment option specified Instructions An instruction box for information xyz Finding following clinical assessment, leading to treatment modalities Special Special instructions Reassess the patient instructions Which the Practitioner must follow Reassess following intervention

AP A skill or sequence that only Request Contact Ambulance Control and request pertains to Advanced Paramedic ALS Advanced Life Support (AP or doctor) Special authorisation Special This authorises the Practitioner to Consider Consider requesting an ALS response, authorisation perform an intervention under specified ALS based on the clinical findings conditions Consider requesting a Consider Paramedic response, based on 4/5/6.4.1 CPG numbering system Paramedic Version 2, 07/11 4/5/6 = clinical levels to which the CPG pertains the clinical findings 4/5/6.x.y x = section in CPG manual, y = CPG number in sequence Consider Version 2, mm/yy mm/yy = month/year CPG published Medical Consider medical oversight

Oversight

Medication, dose & route A medication which may be administered by an EMT or higher clinical level The medication name, dose and route is specified

Medication, dose & route A medication which may be administered by a Paramedic or higher clinical level The medication name, dose and route is specified

Medication, dose & route A medication which may be administered by an Advanced Paramedic The medication name, dose and route is specified A direction to go to a specific CPG following a decision process Go to xxx CPG Note: only go to the CPGs that pertain to your clinical level

Start from A clinical condition that may precipitate entry into the specific CPG 14 Clinical Practice Guidelines

SECTION 1 CARE PRINCIPLES

Care principles are goals of care that apply to all patients. Scene safety, standard precautions, patient assessment, primary and secondary surveys and the recording of interventions and medications on the Patient Care Report (PCR) or the Ambulatory Care Report (ACR) are consistent principles throughout the guidelines and reflect the practice of practitioners. Care principles are the foundations for risk management and the avoidance of error.

PHECC Care Principles

1 Ensure the safety of yourself, other emergency service personnel, your patients and the public.

2 Seek consent prior to initiating interventions and/or administering medications.

3 Identify and manage life-threatening conditions.

4 Ensure adequate ventilation and oxygenation.

5 Optimise tissue perfusion.

6 Provide appropriate pain relief.

7 Identify and manage other conditions.

8 Place the patient in the appropriate posture according to the presenting condition.

9 Ensure the maintenance of normal body temperature (unless a CPG indicates otherwise).

10 Provide reassurance at all times.

11 Monitor and record patient’s vital observations.

12 Maintain responsibility for patient care until handover to an appropriate practitioner.

13 Arrange transport to an appropriate medical facility as necessary and in an appropriate time frame.

14 Complete patient care records following an interaction with a patient.

15 Identify the clinical leader on scene; this shall be the most qualified practitioner on scene. In the absence of a more qualified practitioner, the practitioner providing care during transport shall be designated the clinical leader as soon as practical.

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SECTION 2 PATIENT ASSESSMENT

4/5/6.2.1 Version 3, 02/14 Primary Survey Medical – Adult EMT P BTEC AP

Medical Take standard infection control precautions issue

The primary survey is focused on establishing the patient’s clinical status Consider pre-arrival information and only applying interventions when they are essential to maintain life. It should be completed within one Scene safety minute of arrival on scene. Scene survey Scene situation

Assess responsiveness

A No Airway patent & protected

Suction, Head tilt/ Yes OPA chin lift P NPA

Consider EMT B Special Authorisation: No Adequate Oxygen therapy EMTs having completed ventilation the BTEC course may be privileged by a licensed Yes CPG provider to insert an NPA on its behalf C No Adequate circulation

Yes

AVPU assessment

Life Non serious Clinical status decision threatening or life threat

Serious not life threat

Go to Request Go to Consider Secondary appropriate Survey ALS CPG ALS CPG

Reference: ILCOR Guidelines 2010

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SECTION 2 PATIENT ASSESSMENT

4/5/6.2.2 Version 3, 02/14 Primary Survey Trauma – Adult EMT P BTEC AP Trauma Take standard infection control precautions

Consider pre-arrival information The primary survey is focused on establishing the patient’s clinical status and only applying interventions when Scene safety they are essential to maintain life. Scene survey It should be completed within one Scene situation minute of arrival on scene.

Control catastrophic external haemorrhage

Mechanism of C-spine No injury suggestive Yes control of spinal injury

Assess responsiveness

A No Airway patent & protected Suction, OPA Jaw thrust Yes P NPA

EMT B Consider Special Authorisation: No Adequate Oxygen therapy EMTs having completed ventilation the BTEC course may be privileged by a licensed Yes CPG provider to insert an NPA on its behalf C No Adequate circulation

Yes

AVPU assessment

Treat life-threatening injuries only at this point

Life Non serious Clinical status decision threatening or life threat

Maximum time on Serious not scene for life- threatening life threat trauma: ≤ 10 minutes

Go to Request Go to Consider Secondary appropriate Survey ALS CPG ALS CPG

Reference: ILCOR Guidelines 2010

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SECTION 2 PATIENT ASSESSMENT

5/6.2.4 Version 2, 09/11 Secondary Survey Medical – Adult P AP 5/6.2.4 Version 2, 09/11 Secondary Survey Medical – Adult P AP Primary Survey Primary Survey Record vital signs & GCS Record vital signs & GCS

Patient acutely Yes Markers identifying acutely unwell unwell Cardiac chest pain Patient acutely Yes AcuteMarkers pain identifying > 5 acutely unwell unwell Cardiac chest pain No Acute pain > 5 No Focused medical history of presenting Focusedcomplaint medical history of presenting complaint SAMPLE history

SAMPLE history Request Relevant family & social history Go to Identify positive findings Request Relevant family & ALS appropriate and initiate care social history GoCPG to Identifymanagement positive findings ALS appropriate and initiate care Check for medications CPG management carried or medical Checkalert for jewellery medications carried or medical alert jewellery

Examine body systems as appropriate Examine body systems as appropriate

Reference: Sanders, M. 2001, Paramedic Textbook 2nd Edition, Mosby Gleadle, J. 2003, History and Examination at a glance, Blackwell Science Reference: Sanders,Rees, JE, M. 2003, 2001, Early Paramedic Warning Textbook Scores, World2nd Edition, Anaesthesia Mosby Issue 17, Article 10 Gleadle, J. 2003, History and Examination at a glance, Blackwell Science Rees, JE, 2003, Early Warning Scores, World Anaesthesia Issue 17, Article 10

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SECTION 2 PATIENT ASSESSMENT

5/6.2.5 Version 2, 01/13 Secondary Survey Trauma – Adult P AP 5/6.2.5 Version 2, 01/13 Secondary Survey Trauma – Adult P AP Primary PrimarySurvey Survey Markers for multi- system trauma Yes Markers for multi- present system trauma Yes present No No Examination of ECG & SpO2 obvious injuries monitoring Examination of ECG & SpO2 obvious injuries monitoring Monitor and record vital signs Monitor and & GCS record vital signs & GCS Request SAMPLE history Go to Identify positive findings Request appropriate and initiate care ALS Go to Identify positive findings SAMPLE history CPG management appropriate and initiate care ALS CPG management Complete a detailed physical exam (head to Complete a detailed toe survey) as history physical exam (head to dictates toe survey) as history dictates

Check for medications carried or medical Check for medications alert jewellery carried or medical alert jewellery

Consider repeat primary survey Consider repeat primary survey Markers for multi-system trauma GCS < 13 SystolicMarkers BP for < multi-system 90 trauma GCS < 13 Respiratory rate < 10 or > 29 Systolic BP < 90 Heart rate > 120 Respiratory rate < 10 or > 29 Revised Trauma Score < 12 Heart rate > 120 Mechanism of Injury Revised Trauma Score < 12 Mechanism of Injury

Revised Trauma Score Respiratory 10 – 29 4 RateRevised Trauma > 29 Score 3 Respiratory 10 – 29 4 6 – 9 2 Rate > 29 3 1 – 5 1 6 – 9 2 00 1 – 5 1 Systolic BP ≥ 90 4 00 76 – 89 3 Systolic BP ≥ 90 4 50 – 75 2 76 – 89 3 1 – 49 1 50 – 75 2 no BP 0 1 – 49 1 GCS 13 – 15 4 no BP 0 9 – 12 3 GCS 13 – 15 4 6 – 8 2 9 – 12 3 4 – 5 1 6 – 8 2 30 4 – 5 1 RTS = Total score 30 RTS = Total score

Reference: McSwain, N. et al, 2011, PHTLS Prehospital Trauma Life Support, 7th Edition, Mosby Reference: McSwain, N. et al, 2011, PHTLS Prehospital Trauma Life Support, 7th Edition, Mosby 19 Clinical Practice Guidelines

SECTION 2 PATIENT ASSESSMENT

4/5/6.2.6 Version 4, 02/14 Pain Management – Adult EMT P

AP Pain

Analogue Pain Scale Pain assessment 0 = no pain……..10 = unbearable Practitioners, depending on his/her scope of practice, may make a clinical judgement and commence pain relief on a higher rung Administer pain medication based on of the pain ladder. pain assessment and pain ladder recommendations

Adequate relief Yes or best achievable of pain

No

Go back Reassess and move to up the pain ladder if originating appropriate CPG

Repeat Fentanyl g IN IN, once only, at l 0.1 m entany n not < 10 min after Request F t x 1 pr Repea initial dose. ALS or and / Severe pain g IV ne 2 m Repeat Morphine at (≥ 7 on pain scale) Morphi not < 2 min intervals if indicated. Max 10 mg / or For musculoskeletal and pain Max 16 mg en, Oxyg ide & Consider us Ox O Nitro inh Paramedic 1 g P amol racet Pa r nd / o Moderate pain a g PO 00 m er IV (4 to 6 on pain scale) en 4 onsid mg prof C etron 4 Ibu ndans O slowly / or and or IV 50 mg gen, izine Oxy Cycl y ide & slowl us Ox Nitro inh ions g PO vent mol 1 nter aceta cal i Mild pain Par ologi rmac (1 to 3 on pain scale) -pha on er r n Ladd othe Pain ider ECC Cons PH Decisions to give analgesia must be based on clinical assessment and not directly on a linear scale

Special Authorisation: AP APs are authorised to administer Morphine, up to 10 mg IM, if IV not accessible, the patient is cardiovascularly stable and no cardiac chest pain present

Reference: World Health Organization, Pain Ladder

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SECTION 3 RESPIRATORY EMERGENCIES

5/6.3.1 Version 3, 03/14 Advanced Airway Management – Adult P AP

Apnoea or special clinical considerations

Special clinical considerations Ventilations Consider GCS = 3 No maintained FBAO SpO2 < 92% RR ≤ 9 BVM ineffective Yes (All of the above must be present)

Supraglottic airway insertion Paramedic: Maximum two attempts at supraglottic airway insertion. or Advanced paramedic: Maximum two attempts at AP ETT and maximum two attempts at supraglottic Endotracheal intubation airway insertion (either as primary device or rescue from failed ETT)

Successful Yes

Maintain adequate No ventilation and oxygenation throughout procedures Ensure CO2 detection Revert to basic airway device in ventilation management circuit

Check placement of advanced airway after each patient movement or if any patient deterioration

Minimum interruptions of chest compressions. Continue ventilation and oxygenation AP Maximum hands off time Consider use 10 seconds. of waveform Go to capnography appropriate CPG

Following successful Advanced Airway management:- i) Ventilate at 8 to 10 per minute. ii) Unsynchronised chest compressions continuous at 100 to 120 per minute

Reference: ILCOR Guidelines 2010

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SECTION 3 RESPIRATORY EMERGENCIES

4/5/6.3.2 Version 2, 05/14 Inadequate Ventilations – Adult EMT P

AP Respiratory Airway Go to patent & No Airway difficulty protected CPG

Yes P Consider Raised ETCO2 + reduced SpO2: Check SpO2 ETCO 2 Consider assisted ventilation

Raised ETCO2 + normal SpO2: 100% O2 initially unless Oxygen therapy Encourage deep breaths patient has known COPD Titrate O2 to standard as clinical condition improves Request

ALS

Patient assessment

Consider positive pressure ventilations (Max 10 per minute)

Brain insult Respiratory failure Substance intake Other

Go to Go to Respiratory assessment Go to Consider pain, posture & Head Stroke Poison neuromuscular disorders injury CPG CPG CPG

Bronchospasm/ Asymmetrical Crepitations Other known asthma breath sounds

Go to Go to Go to Go to Consider shock, cardiac/ Asthma Allergy/ COPD EMT Sepsis neurological/ systemic CPG Anaphylaxis CPG CPG illness, pain or CPG psychological upset

Go to Consider collapse, APO CPG consolidation & fluid

Tension Yes Pneumothorax No suspected AP Needle decompression

22 Clinical Practice Guidelines

SECTION 3 RESPIRATORY EMERGENCIES 4/5/6.3.3 Version 2, 02/14 Exacerbation of COPD EMT P

4/5/6.3.3 AP Version 2, 02/14 Dyspnoea Exacerbation of COPD EMT P

AP History of Dyspnoea No COPD

HistoryYes of No Oxygen Therapy COPD 1. if O2 alert card issued follow directions. Oxygen therapy 2. if no O2 alert card, commence therapy at 28% Yes 3. administer O titrated to SpO 92% Oxygen Therapy2 2 1. if O2 alert card issued follow directions. Oxygen therapy 2. if no O2 alert card, commence therapy at 28% ECG & SpO2 3. administer O2 titrated to SpO2 92% monitor

ECG & SpO2 P monitor Measure Peak Expiratory Flow P Measure Peak Expiratory Flow Salbutamol 5 mg NEB

Salbutamol 5 mg NEB PEF < 50% No predicted Go to PEFYe < s50% Inadequate No predicted Ventilations CPG Go to RequestYes Inadequate Ventilations ALS CPG Request

Ipratropium bromideALS 0.5 mg NEB & salbutamol 5 mg NEB mixed

Ipratropium bromide 0.5 mg NEB & salbutamolDeteriorates 5 mg NEB mixed No /unstable

DeterioratesYes No /unstable Hydrocortisone 200 mg IV (in 100 mLYe NaCl)s or IM

Hydrocortisone 200 mg IV (in 100 mL NaCl) or IM

Adequate No respirations

AdequateYes No respirations

Yes

An exacerbation of COPD is defined as; An event in the natural course of the disease characterised by a change in the patient’s baseline dyspnoea, cough and/or sputum beyond day-to- day variability sufficient to warrant a change in management. (European Respiratory Society) An exacerbation of COPD is defined as; An event in the natural course of the disease characterised by a change in the patient’s baseline dyspnoea, cough and/or sputum beyond day-to- day variability sufficient to warrant a change in management. (European Respiratory Society)

23 Clinical Practice Guidelines

SECTION 3 RESPIRATORY EMERGENCIES

4/5/6.3.4 Version 2, 05/14 Asthma – Adult EMT P

Asthma/ AP bronchospasm Assess and maintain airway

Respiratory assessment

Salbutamol, 5 mg, NEB

Mild Asthma OR Salbutamol If no improvement Salbutamol (0.1 mg) metered aerosol aerosol, 0.1 mg may be repeated up to 5 times as required

Resolved/ Yes improved

No

ECG & SpO2 monitoring

Oxygen therapy

Request

ALS

Salbutamol, 5 mg, NEB OR Moderate Asthma Ipratropium bromide 0.5 mg NEB & salbutamol 5 mg NEB mixed

Resolved/ Yes improved

No

Salbutamol, 5 mg, NEB

Resolved/ Yes improved

No

Hydrocortisone, 100 mg slow IV Severe Asthma (infusion in 100 mL NaCl)

Salbutamol, 5 mg, NEB

Resolved/ Yes improved

No

Life-threatening Consider Asthma Magnesium Sulphate 2 g IV (infusion in 100 mL NaCl)

Salbutamol, 5 mg, NEB Every 5 minutes prn

Reference: HSE National Asthma Programme 2012, Emergency Asthma Guidelines, British Thoracic Society, 2008, British Guidelines on the Management of Asthma, a national clinical guideline 24 Clinical Practice Guidelines

SECTION 3 RESPIRATORY EMERGENCIES

5/6.3.5 Version 1, 12/13 Acute Pulmonary Oedema – Adult P AP

Respiratory distress with Congestion / crepitations Oxygen therapy

SpO2, ECG & BP monitoring

Go to 12 Lead ECG STEMI ACS CPG

Go to Pulmonary Inadequate No oedema Respirations CPG Yes

GTN, 0.8 mg, SL Repeat x 1 prn

Reassess

Meets criteria No for CPAP

Yes

Apply Continuous Positive Airway Oxygen Pressure (CPAP) device Adequate flow to drive CPAP

Systemic fluid Yes retention

Furosemide, 40 mg, IV No

Bradycardia Yes

Criteria for CPAP Atropine, 0.6 mg IV Clinical signs of APO No Repeat to Max 3 mg prn RR > 25 per min SpO2 < 90%

Exclusion Criteria COPD / Asthma Inability to sit up Pneumothorax Need for immediate intubation SBP < 100 mmHg / cardiovascular collapse CPAP Life-threatening arrythmia Commence with 5 cm H2O Reduced GCS (AVPU < V) Titrate up to 10 cm H2O as tolerated Unable to tolerate CPAP Monitor clinical response Vomiting Titrate O2 to maintain SpO2 > 95%

Reference: Williams, B et al 2013, When Pressure is Positive: A Literature Review of the Prehospital Use of Continuous Positive Airway Pressure. Prehosp Disaster med, 1-10. 25 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

4/5/6.4.1 Version 2, 06/11 Basic Life Support – Adult EMT P

AP

Cardiac Initiate mobilisation of 3 to 4 Arrest practitioners / responders on site to assist with cardiac arrest management Request

ALS

Chest compressions Rate: 100 to 120/ min Attach defibrillation pads Depth: at least 5 cm Commence CPR while defibrillator is being prepared only if 2nd person available 30 Compressions : 2 ventilations. Oxygen therapy Ventilations Rate: 10/ min (1 every 6 sec) Volume: 500 to 600 mL

AP Change defibrillator to manual mode Shockable Assess Non - Shockable VF or pulseless VT Rhythm Asystole or PEA P Consider changing defibrillator to manual mode Give 1 shock

Continue CPR while defibrillator is charging Minimum interruptions of Immediately resume CPR x 2 minutes chest compressions.

Maximum hands off time 10 seconds.

Rhythm check *

Go to VF/ Go to Post Pulseless VT VF/ VT ROSC Resuscitation CPG Care CPG

Go to Go to PEA Asystole Asystole PEA CPG CPG

If an Implantable Cardioverter Defibrillator (ICD) is fitted in the patient treat as per CPG. It is safe to touch a patient with an ICD fitted even if it is firing.

* +/- Pulse check: pulse check after 2 minutes of CPR if potentially perfusing rhythm

Reference: ILCOR Guidelines 2010

26 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

4/5.4.2 EMT P Version 1, 05/08 Foreign Body Airway Obstruction – Adult

Are you FBAO choking?

Severe FBAO Mild (ineffective cough) Severity (effective cough)

No Conscious Yes Encourage cough

1 to 5 back blows followed by 1 to 5 abdominal thrusts as indicated

Yes Request Adequate No Conscious No Effective Yes Yes ventilations ALS

No

Positive pressure One cycle of CPR ventilations maximum 10 per minute

Consider Effective Yes Oxygen therapy

No

One cycle of CPR

Effective Yes

No Oxygen therapy

Go to BLS Adult CPG

After each cycle of CPR open mouth and look for object. If visible attempt once to remove it

27 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

4/5/6.4.3 EMT P Version 2, 03/11 VF or Pulseless VT – Adult

AP From BLS VF or VT Adult CPG arrest

Refractory VF/VT post Epinephrine AP Amiodarone 300 mg (5 mg/kg) IV/ IO Immediate IO access if IV 2nd dose (if required) not immediately accessible Amiodarone 150 mg (2.5 mg/kg) IV/ IO

Go to Post Resuscitation ROSC Care CPG

Defibrillate Yes

Go to PEA No PEA CPG VF/VT

Advanced airway management NaCl IV/IO 500 mL Go to (use as flush) Asystole Asystole Rhythm Consider CPG check * mechanical Epinephrine (1:10 000) 1 mg IV/IO CPR assist Every 3 to 5 minutes prn

If torsades de pointes, consider Initial Epinephrine Magnesium Sulphate 2 g IV/IO between 2nd and 4th shock

Consider transport to ED if no change after 20 minutes resuscitation

If no ALS available

With CPR ongoing maximum hands off time 10 seconds Continue CPR during charging

Mechanical CPR device is the optimum care during transport Drive smoothly Initiate mobilisation of 3 to 4 practitioners / responders Consider causes and treat as Clinical leader to on site to assist with cardiac appropriate: monitor quality arrest management Hydrogen ion acidosis of CPR Hyper/ hypokalaemia Hypothermia AP Hypovolaemia Consider use Hypoxia of waveform Thrombosis – pulmonary capnography Tension pneumothorax Thrombus – coronary If Tricyclic Antidepressant Toxicity or Tamponade – cardiac harness induced suspension trauma consider AP Special Authorisation: Toxins Sodium Bicarbonate (8.4%) 1 mEq/Kg IV Trauma Advanced Paramedics are authorised to substitute Amiodarone with a one off bolus * +/- Pulse check: pulse check after 2 minutes of CPR if potentially perfusing rhythm of Lidocaine (1-1.5 mg/Kg IV) if Amiodarone is not available Reference: ILCOR Guidelines 2010

28 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

5/6.4.4 Version 2, 03/11 Asystole – Adult P AP

From BLS Adult Asystole Initiate mobilisation of 3 to 4 CPG practitioners / responders on site to assist with cardiac AP arrest management Immediate IO access if IV not immediately accessible

Go to Post Resuscitation ROSC Care CPG

Yes

Go to PEA No PEA CPG Asystole

Advanced airway Go to VF / management Pulseless VT VF/VT Rhythm CPG Epinephrine (1:10 000) 1 mg IV/ IO check * Every 3 to 5 minutes prn Consider mechanical CPR assist

NaCl IV/IO 500 mL Following 10 minutes (use as flush) of asystole Go to Asystole decision CPG

With CPR ongoing maximum hands off time 10 seconds

Clinical leader to monitor quality of CPR

Consider causes and treat as appropriate: Hydrogen ion acidosis Hyper/ hypokalaemia AP Consider use Hypothermia of waveform Hypovolaemia capnography Hypoxia Thrombosis – pulmonary Tension pneumothorax Thrombus – coronary If Tricyclic Antidepressant Toxicity or Consider fluid challenge Tamponade – cardiac harness induced suspension trauma consider Toxins NaCl 20 mL/Kg IV/IO Sodium Bicarbonate (8.4%) 1 mEq/Kg IV Trauma

* +/- Pulse check: pulse check after 2 minutes of CPR if potentially perfusing rhythm

Reference: ILCOR Guidelines 2010

29 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

5/6.4.5 P AP Version 1, 05/08 Asystole - Decision Tree

From From Asystole – Traumatic Adult Asystole Cardiac CPG Arrest CPG

Traumatic Patient is; Hypothermic or Cardiac Arrest Cold water drowning or Yes No Poisoning/ Overdose or Pregnant or < 18 years Witnessed arrest & CPR prior to Yes arrival of EMS

Resuscitation continuous for No at least 20 minutes in asystole

Confirm Asystolic Cardiac Arrest Unresponsive No signs of life; absence of central pulse and respiration

Confirm that (two minutes of CPR and no shock advised) x 3 are completed

Consider ceasing No resuscitation efforts

Yes

Record two rhythm strips x 10 sec duration

Record on ECG strips PCR No Patient’s name Date and time

Continue BLS & or ALS Inform Ambulance Control

Emotional support If present, inform for relatives should If no ALS available next of kin be considered before leaving the scene

Complete PCR and flag for mandatory clinical audit

Follow local protocol for care of deceased

30 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

4/5/6.4.6 Version 2, 03/11 Pulseless Electrical Activity – Adult EMT P

AP From BLS Adult PEA CPG Initiate mobilisation of 3 to 4 practitioners / responders on site to assist with cardiac AP arrest management Immediate IO access if IV not immediately accessible

Go to Post Resuscitation ROSC Care CPG

Yes

Go to Asystole Asystole No PEA CPG

Advanced airway management Go to VF / Rhythm Pulseless VT VF/VT Epinephrine (1:10 000) 1 mg IV/ IO Consider CPG check * Every 3 to 5 minutes prn mechanical CPR assist

NaCl IV/IO 500 mL (use as flush)

Consider transport to ED if no change after 20 minutes resuscitation

If no ALS available

With CPR ongoing maximum hands off time

Mechanical CPR device is 10 seconds the optimum care during transport Drive smoothly

Clinical leader to Consider causes and treat as appropriate: monitor quality Hydrogen ion acidosis of CPR Hyper/ hypokalaemia Hypothermia AP Consider use Hypovolaemia of waveform Hypoxia capnography Thrombosis – pulmonary Tension pneumothorax Thrombus – coronary If Tricyclic Antidepressant Toxicity or Tamponade – cardiac harness induced suspension trauma consider Consider fluid challenge Toxins NaCl 20 mL/Kg IV/IO Trauma Sodium Bicarbonate (8.4%) 1 mEq/Kg IV

* +/- Pulse check: pulse check after 2 minutes of CPR if potentially perfusing rhythm

Reference: ILCOR Guidelines 2010

31 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

5/6.4.7 Version 3, 11/13 Post-Resuscitation Care – Adult P AP Return of Spontaneous Maintain Oxygen therapy

Circulation Titrate O2 to 94% - 98% Request

ALS

Initiate mobilisation of 3 to 4 practitioners / responders Adequate on site to assist with cardiac No ventilation arrest management Positive pressure ventilations Max 10 per minute Yes

Avoid 12 lead ECG hyperthermia

Go to Yes STEMI ACS CPG No

Maintain patient at rest If persistent hypotensive consider NaCl (0.9%) IV/IO ECG & SpO2 monitoring to maintain Sys BP > 90 mmHg

Monitor blood pressure and GCS

Symptomatic Bradycardia Ventricular Tachycardia arrhythmia Atropine 0.6 mg IV/IO Consider Repeat at 3 to 5 min intervals prn Amiodarone, 150 mg IV/IO infusion No to max 3 mg (in 100 mL D5W)

Check blood glucose

Consider causes and treat as appropriate: Hydrogen ion acidosis Unresponsive No Hyper/ hypokalaemia Hypothermia Hypovolaemia Yes Hypoxia Thrombosis – pulmonary Commence cooling Tension pneumothorax Equipment list Thrombus – coronary (Target 32o to 34o C) Tamponade – cardiac Cold packs Toxins Trauma NaCl (4o C approx) 1 L IV/IO Repeat x 1 if required

Monitor vital signs

When ALS available consider transporting to primary PCI facility (follow local protocol)

Reference: ILCOR Guidelines 2010 32 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

5/6.4.8 P Version 1, 06/10 End of Life – DNR AP

End stage Patient becomes terminal acutely unwell illness

The dying patient, along Respiratory Yes with his/her family, is viewed distress as a single unit of care Basic airway maintenance No

Oxygen therapy

A planned ambulance transport is a scheduled Planned discharge to home or an Confirm and agree Yes ambulance No interfacility patient transport procedure with transport clinical staff in the event of a death in transit Recent & Recent & reliable written reliable evidence from a instruction from patient’s No clinical source stating that No doctor stating that the the patient is not for patient is not for resuscitation resuscitation Go to Go to Primary Primary Survey Yes Yes Survey CPG CPG

Agreement between caregivers present and Practitioners No not to resuscitate

Yes

It is inappropriate to commence resuscitation

Inform Ambulance Control

Yes Pulse present Appropriate Practitioner Provide supportive Registered Medical Practitioner care until handover No Registered Nurse to appropriate Registered Advanced Paramedic Practitioner Registered Paramedic Registered EMT Consult with Ambulance Follow local Control re; ‘location to protocol for care transport patient / of deceased deceased’

Complete all appropriate documentation

Emotional support Keep next of kin for relatives should informed, if be considered before present leaving the scene

33 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

5/6.4.9 Version 2, 06/11 Recognition of Death – Resuscitation not Indicated P AP

Apparent dead body

Signs of Life Yes

No Go to Primary survey CPG

Definitive indicators of No Death Yes

It is inappropriate to commence resuscitation

Inform Ambulance Control

Complete all appropriate documentation

Emotional support Inform next of kin, for relatives should if present be considered before leaving the scene

Follow local protocol for care of deceased

Definitive indicators of death: 1. Decomposition 2. Obvious rigor mortis 3. Obvious pooling (hypostasis) 4. Incineration 5. Decapitation 6. Injuries totally incompatible with life 7. Unwitnessed traumatic cardiac arrest following blunt trauma (see CPG 5/6.6.11)

34 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

5/6.4.10 Acute Coronary Syndrome P AP Version5/6.4.10 6, 02/14 Version 6, 02/14 Acute Coronary Syndrome P AP Acute Coronary MP AcuteSyndrom Coronarye MP Syndrome Oxygen therapy Oxygen therapy Oxygen therapy STEMI: OxygenMaintain therapySpO2 between STEMST elevationI: in two or more Request 94%Main tatoin 98% SpO between STcontiguous elevation leads in two (2 ormm more in leads Request 2 94%(lower to range 98% if COPD) contiguousV2 and V3, leadsor 1 mm (2 mmin any in leadsother ALS (lower range if COPD) V2leads) and or V3, LBBB or 1 withmm clinicalin any other ALS symptomsleads) or LBBB of AMI. with clinical symptoms of AMI. Apply 3 lead ECG & SpO monitor MP Apply 3 2lead ECG & SpO2 monitor MPIndication for Thrombolysis Indication1. Patient co fornsci ouThrombolysiss, coherent and understands therapy Aspirin 300 mg PO 2.1. Patient consenscintou obs, taicohenedrent and understands therapy Aspirin 300 mg PO 3.2. PatieLess ntthan co nse75 yearsnt obtai oldned 3.4. LessMI Symptoms than 75 years > 20 Minold & ≤ 6 hours No Chest Pain Yes 4.5. MConfirmedI Symptoms STEMI > 20 Min & ≤ 6 hours No Chest Pain Yes 5.6. ConfirmedTime to PP STEMICI centre > 90 minutes of STEMI GTN 0.4 mg SL 6 . Timconfirmatione to PPCI once ntre12 lead > 90 ECG minutes of STEMI Repeat prnGTN to 0.4 max mg of SL 1.2 mg SL 7. Noconfirmation contraindic onations 12 lead prese ECGnt Repeat prn to max of 1.2 mg SL 7. No contraindications present Acquire & interpret Pain relief Yes Acquire12 lead & interpretECG Paineffective relief Yes 12 lead ECG effective No No No STEMI No STEMI Go to Pain Yes GoMgt. to CPG Pain Yes Mgt. CPG

Time to PPCI Discuss with CentreTime < 90 tomin PPCI of STEMI Yes PPCI Centreidentification < 90 min of on STEMI Discuss with Yes Physician identification12 lead ECG on PPCI 12 lead ECG Physician

No No

Clopidogrel, 300 mg, PO Ticagrelor 180 mg PO Clopidogrel,(≥ 75 years, 30075 mg mg, PO) PO Ticagrelor 180 mg PO (≥ 75 years, 75 mg PO)

Pre-hospital No thPre-hospitalrombolysis No thavailablerombolysis available Yes Yes

Tenecteplase IV MP Tenecteplase IV MP Followed by Patients age > 75 years do not give EnoxaparinFollowed 30 bymg IV PaIV tiEnoxaparinents age > but75 years rather do Enoxaparin not give (> 75 Yrs:Enoxaparin Enoxaparin 30 0.75 mg mg/KgIV SC) 0.75mg/kgIV Enoxaparin SC (maxbut rather 75 mg Enoxaparin SC) (> 75 Yrs: Enoxaparin 0.75 mg/Kg SC) 0.75mg/kg SC (max 75 mg SC)

Time critical Transport to Tenecteplase commenceTime crittransportical to TPrimaryranspo rtPCI to < 60 kg 30 mg Tenecteplase commencenearest appropriate transport to Primaryfacilit yPCI <60 60 – 70kg kg 3530 mg hospital ASAP nearest appropriate facility 7060 – 8070 kg 4035 mg hospital ASAP 8070 – 9080 kg 4540 mg >80 90 – 90kg kg 4550 mg > 90 kg 50 mg

Reference: HSE ACS Programme 2013, ILCOR Guidelines 2010, ECS Guidelines 2010 Reference: HSE ACS Programme 2013, ILCOR Guidelines 2010, ECS Guidelines 2010 35 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

4/5/6.4.11 Version 2, 02/14 Symptomatic Bradycardia – Adult EMT P

AP Symptomatic Bradycardia Oxygen therapy

Symptomatic includes; Acute altered mental status Request Ischemic chest discomfort Acute heart failure ALS Hypotension Signs of shock

ECG & SpO2 monitoring

Atropine, 0.6 mg IV Titrate Atropine to Repeat at 3 to 5 min intervals prn to max 3 mg effect (HR > 60)

P 12 lead ECG

NaCl (0.9%) 250 mL IV infusion (Repeat x one prn)

Reassess

Reference: ILCOR guidelines 2010 36 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

5/6.4.12 Version 1, 02/14 Tachycardia – Adult P AP

Tachycardia

ECG and SpO2 monitoring

Oxygen therapy

Request Acquire 12 lead ECG ALS

No HR > 150 /min

Yes Persistent tachyarrhythmia causing any of; - Hypotension - Acutely altered mental status No Symptomatic - Signs of shock - Ischaemic chest discomfort - Acute heart failure Yes

No Unstable Yes

QRS Complex

Narrow Broad

Irregular Regular Regular Irregular

Torsades de AP V Fib Consider cardioversion pointes Narrow regular = 50 J (synch on) if unresponsive

Go to VF/ Pulseless Yes VT CPG Amiodarone 150 mg IV No infusion (in 100 mL D5W)

Yes Converted QRS Complex No Magnesium Sulphate 2 g IV Narrow Broad infusion (in 100 mL NaCl)

Regular Irregular Regular AP Consider if VT likely Consider cardioversion Valsalva / Amiodarone 150 mg IV Broad regular = 100 J vagal infusion (in 100 mL D W) (synch on) if unresponsive Manoeuvre 5

P Special Authorisation: Paramedics are authorised to continue the established infusion in the absence of an Advanced Paramedic or Doctor during transportation

Reference: ILCOR Guidelines 2010 37 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

5/6.4.13 Version 1, 12/13 Adrenal Insufficiency – Adult P AP

Diagnosed with Addison’s disease or Adrenal insufficiency Recent illness or No injury Yes

Check blood glucose

SBP < 90 No mmHg

Yes

Request

ALS

Consider Hydrocortisone 100 mg IM Hydrocortisone 100 mg IV if IV not available (in 100 mL NaCl)

Reassess

NaCl (0.9%) 1 L IV infusion

P Special Authorisation: Paramedics are authorised to continue the established infusion in the absence of an Advanced Paramedic or Doctor during transportation

Reference:

38 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

5/6.4.14 Version 1, 05/08 Altered Level of Consciousness – Adult P AP

V, P or U on AVPU scale

Maintain airway

No Trauma Yes

Consider Consider recovery position Cervical Spine

Obtain SAMPLE history from patient, relative or bystander

ECG & SpO2 monitoring Calculate GCS

Check temperature Check pupillary size & response Check for skin rash Go to Shock from Go to Anaphylaxis CPG blood loss CPG Check for medications carried or medical alert jewellery Submersion Go to Go to Symptomatic incident CPG CPG Bradycardia Check blood glucose

Go to Glycaemic Go to Head injury CPG emergency CPG

Differential Diagnosis Go to Inadequate Go to Hypothermia CPG respirations CPG

Go to Post Poison Go to CPG resuscitation CPG care

Go to Go to Seizures Septic shock CPG CPG

Go to Go to Stroke Taser gun CPG CPG

39 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

5/6.4.15 Version 2, 07/11 Allergic Reaction/Anaphylaxis – Adult P AP

Allergic reaction Oxygen therapy

Severe/ Mild Moderate Anaphylaxis

Epinephrine administered pre No arrival? (within 5 minutes)

Epinephrine (1:1 000) 0.5 mg (500 mcg) IM Yes Repeat at 5 minute intervals if no improvement Monitor reaction

Request

ALS

Reassess

If bronchospasm consider nebuliser Recurs / deteriorates / No no improvement Salbutamol 5 mg NEB

Yes Reassess

ECG & SpO2 ECG & SpO2 monitor monitor

Request Deteriorates Yes Epinephrine (1:1 000) 0.5 mg (500 mcg) IM ALS No NaCl (0.9%) 1 L IV/IO infusion Repeat by one prn

If bronchospasm consider nebuliser Salbutamol 5 mg NEB

Severe or recurrent reactions Yes and or patients with asthma Hydrocortisone 200 mg IV (in 100 mL NaCl) or IM No

Mild Urticaria and or angio oedema Special Authorisation: Paramedics are authorised to continue Severe/ anaphylaxis P the established infusion in the absence Moderate Moderate symptoms + of an Advanced Paramedic or Doctor Mild symptoms + simple haemodynamic and or bronchospasm respiratory compromise during transportation

40 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

4/5/6.4.16 Version 2, 07/11 Decompression Illness (DCI) EMT P

AP SCUBA diving within 48 hours Complete primary survey Consider diving (Commence CPR if appropriate) buddy as possible patient also Treat in supine position

Oxygen therapy

100% O2

Request

ALS

Conscious No

Maintain Airway, Yes Breathing & Circulation

Go to Entonox absolutely Pain relief Pain Mgt. Yes contraindicated required CPG

No

AP Go to Nausea & Yes Nausea Vomiting CPG No

Monitor ECG & SpO2

NaCl (0.9%) 500 mL IV/IO

Notify control of query DCI & alert ED

Transport dive computer and diving equipment Transport is completed at an with patient, if possible altitude of < 300 metres above incident site or aircraft pressurised equivalent to sea level

Special Authorisation: P Paramedics are authorised to continue the established infusion in the absence of an Advanced Paramedic or Doctor during transportation

Reference: The Primary Clinical Care Manual 3rd Edition, 2003, Queensland Health and the Royal Flying Doctor Service (Queensland Section)

41 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

4/5/6.4.17 Version 2, 01/13 Epistaxis EMT P

AP

Primary Primary Survey Medical Trauma Survey Medical Trauma

Advise patient to sit forward

Apply digital pressure for 15 minutes Equipment list

Proprietary nasal Advise patient to breathe pack through mouth only and not to blow nose

Haemorrhage No controlled

Consider Yes

ALS

P Consider insertion of a proprietary nasal pack

Request Go to Hypovolaemic Yes Shock ALS CPG

No

Reference: Management of Acute Epistaxis 2011, Ola Bamimore, MD; Chief Editor: Steven C Dronen, MD, http://emedicine.medscape.com/article/764719- overview#showall

42 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

5/6.4.19 Version 1, 05/08 Glycaemic Emergency – Adult P AP

Abnormal blood glucose level

< 4 mmol/L Blood Glucose 11 to 20 mmol/L

Dextrose 10% 250 mL IV/IO infusion > 20 mmol/L Or Glucagon 1 mg IM Or Glucose gel 10-20 g buccal Consider Or ALS Sweetened drink

Reassess NaCl (0.9%) 1 L IV/IO infusion

Allow 5 minutes to elapse following administration of medication Reassess

Blood Glucose No < 4 mmol/L

Yes

Consider

ALS

Repeat if indicated Dextrose 10%, 250 mL IV/IO infusion Or Glucose gel 10-20 g buccal

Reassess

Special Authorisation: Paramedics are authorised to continue P the established infusion in the absence of an Advanced Paramedic or Doctor during transportation

43 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

5/6.4.21 Version 2, 06/13 Hypothermia P AP

Query hypothermia

Immersion Yes Members of rescue teams should have a clinical Remove patient horizontally from liquid leader of at least EFR level No (Provided it is safe to do so)

Protect patient from wind chill

Pulse check for Complete primary survey 30 to 45 seconds (Commence CPR if appropriate)

Hypothermic patients should be handled gently Remove wet clothing by cutting & not permitted to walk

Equipment list Place patient in dry blankets/ sleeping bag with outer layer of insulation Low reading thermometer Survival bag Space blanket Hot pack ECG & SpO2 monitoring

Check and record core temperature

Mild Moderate Severe 34 – 35.9oC 30 – 33.9oC < 30oC

Give hot sweet drinks

If Cardiac Arrest Follow CPGs but; Follow CPGs but Follow CPGs but; - double medication interval until temperature > 34oC - limit defibrillation to three shocks - no active re-warming o - no active re-warming beyond 32oC - withhold medications until temperature > 30 C - no active re-warming beyond 32oC

Unresponsive Yes Consider No advanced airway

If Bradycardiac

Follow CPGs but; - do not use Atropine until temperature > 34oC

NaCl warmed to 40oC approx Warm fluids to be Adult: 250 mL IV, Repeat prn to max 1 L administered over Paediatric: 10 mL/Kg IV, Repeat prn x 1 30 minutes

Hot packs to Check blood Transport in head down position armpits & groin glucose Helicopter: head forward Boat: head aft Reference: Golden, F & Tipton M, 2002, Essentials of Sea Survival, Human Kinetics AHA, 2005, Part 10.4: Hypothermia, Circulation 2005:112;136-138 Soar, J et al, 2005, European Resuscitation Council Guidelines for Resuscitation 2005, Section 7. Cardiac arrest in special circumstances, Resuscitation (2005) 6751, S135-S170 Pennington M, et al, 1994, Wilderness EMT, Wilderness EMS Institute

44 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

4/5.4.22 Version 3, 02/14 Poisons – Adult EMT P 4/5.4.22 Version 3, 02/14 Poisons – Adult EMT P Poison source Poison source Ingested Yes corrosive Ingested Sips of water Caution with Yes corrosiveNo oral intake or milk Sips of water Caution with No oral intake or milk

Consider

ConsiderALS

ALS

Poison type

Poison type

Paraquat Other Alcohol Opiate

Paraquat Other Alcohol Opiate

With Paraquat Check blood glucose poisoning do not With Paraquat Check blood administer oxygen glucose poisoning do not unless SpO < 92% administer oxygen2 BG No < 4 or > 20 unless SpO2 < 92% mmol/LBG No < 4 or > 20 mmol/LYes

Yes Go to Glycaemic EmergencyGo to GlycaemicCPG Emergency CPG Adequate Yes ventilations Adequate Yes Consider ventilationsNo Oxygen therapy Consider No Oxygen therapy Naloxone 0.8 mg IN (Repeat x one prn) NaloxoneOr 0.8 mg IN Naloxone(Repeat 0.4 x one mg prn)IM/SC (Repeat Orx one prn) ECG & SpO2 Naloxone 0.4 mg IM/SC monitoring (Repeat x one prn) ECG & SpO2 monitoring Go to Inadequate VentilationsGo to InadequateCPG Ventilations CPG

Reference: ILCOR Guidelines 2010 Boyer,Reference: E, 2012, Management of Opioid Analgesic Overdose, N Engl J Med 2012;367:146-55.DOI: 10.1056/NEJMra1202561 ILCOR Guidelines 2010 Boyer, E, 2012, Management of Opioid Analgesic Overdose, N Engl J Med 2012;367:146-55.DOI: 10.1056/NEJMra1202561 45 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

5/6.4.23 P AP Version 3, 02/14 Seizure/Convulsion – Adult

Seizure / convulsion

Consider other causes of seizures Protect from harm Meningitis Head injury Hypoglycaemia Oxygen therapy Eclampsia Fever Poisons Alcohol/drug withdrawal Seizing currently Seizure status Post seizure

Request Consider

ALS ALS

No Yes

IV access

Midazolam 2.5 mg IV/IO Repeat by one prn Or Midazolam 10 mg buccal Diazepam 5 mg IV/IO Repeat by one prn Repeat by one prn Or Midazolam 5 mg IN Repeat by one prn Or Check blood glucose Midazolam 5 mg IM Repeat by one prn Or Diazepam, 10 mg PR Repeat by one prn

Go to Blood glucose Glycaemic Yes < 4 or > 20 mmol/L Emergency Maximum two doses of CPG anticonvulsant medication by Practitioner regardless of route No

Reassess

If pre-Eclampsia/ Eclampsia consider Magnesium Sulphate, 4 g IV (infusion in 100 mL NaCl)

Reference: Tukur, J. and Z. Muhammad (2010). "Management of eclampsia at AKTH: before and after magnesium sulphate." Niger J Med 19(1): 104-107

46 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

4/5/6.4.24 Version 3, 02/14 Sepsis – Adult EMT P

AP Patient unwell Signs of Systemic Inflammatory Response Syndrome (SIRS) - Temperature < 36 or > 38.3oC - Heart rate > 90 If temperature > 38oC consider - Respiratory rate > 20 No - Acutely confused Paracetamol, 1 g PO - Glucose > 7.7 (not diabetic) Has the patient two or more signs (SIRS) Yes

Could this be a severe infection? For example If meningitis suspected - Pneumonia ensure appropriate - Meningitis/ meningococcal disease PPE is worn; - UTI No Mask and goggles - Abdominal pain or distension - Indwelling medical device - Cellulitis/ septic arthritis/ infected wound - Chemotherapy < 6 weeks - Recent organ transplant Yes

ECG & SpO2 monitoring

Oxygen therapy

Commence with 100% O2. Caution with patients with COPD Request

ALS

Benzylpenicillin, 1,200 mg slow IV or IM

Signs of poor Signs of shock/ poor perfusion Yes perfusion Mottled/ cold peripheries Central capillary refill > 2 sec SBP < 90 mmHg No Purpuric rash Absent radial pulse NaCl 0.9%, 500 mL IV/IO NaCl 0.9%, 250 mL, IV/IO

If Sys BP < 100 mmHg consider aliquots

NaCl 0.9%, 250 mL, IV/IO

Pre alert ED if severe sepsis

Special Authorisation: P Paramedics are authorised to continue the established infusion in the absence of an Advanced Paramedic or Doctor during transportation

47 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

5/6.4.25 Version 1, 12/13 Shock from Blood Loss (non-trauma) – Adult P AP

Clinical signs of shock

Control external haemorrhage

Oxygen therapy

Request

ALS

NaCl (0.9%), 500 mL IV/IO

Reassess

NaCl (0.9%), 250 mL IV/IO aliquots to maintain palpable radial pulse (SBP 90 - 100 mmHg)

SpO2 and ECG monitoring

Continue fluid therapy until handover at ED

P Special Authorisation: Paramedics are authorised to continue the established infusion in the absence of an Advanced Paramedic or Doctor during transportation

48 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES 4/5/6.4.27 Version 1, 12/13 Sickle Cell Crisis - Adult EMT P 4/5/6.4.27 Version 1, 12/13 Sickle Cell Crisis - Adult EMT AP P Sickle Cell crisis AP Sickle Cell crisis Oxygen therapy 100% O2

Oxygen therapy 100% O2 Pain Go to management Yes Pain CPG required Pain Go to management Yes No Pain CPG required

No

Go to Elevated Sepsis Yes temperature CPG Go to Elevated Sepsis Yes No temperature CPG

No Consider patient’s If patient is cold ensure that he/she is care plan warmed to normal temperature

Consider patient’s If patient is cold ensure that he/she is care plan warmed to normal temperature Encourage oral fluids

Encourage oral fluids

Dehydration & unable to take oral No fluids Dehydration & unable to take oral No fluidsYes

Yes Request

ALS Request

ALS NaCl (0.9%) 1 L IV infusion

NaCl (0.9%) 1 L IV infusion

SpO2 & ECG monitor

SpO2 & ECG monitor

P Special Authorisation: Paramedics are authorised to continue the established infusion in the P Specialabsence Authorisation: of an Advanced Paramedic or Doctor during transportation Paramedics are authorised to continue the established infusion in the absence of an Advanced Paramedic or Doctor during transportation

Reference: Rees, D, 2003, GUIDELINES FOR THE MANAGEMENT OF THE ACUTE PAINFUL CRISIS IN SICKLE CELL DISEASE; British Journal of Haematology, 2003, 120, 744–752

Reference: Rees, D, 2003, GUIDELINES FOR THE MANAGEMENT OF THE ACUTE PAINFUL CRISIS IN SICKLE CELL DISEASE; British Journal of Haematology, 2003, 120, 744–752

49 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

5/6.4.28 Version5/6.4.28 2, 07/11 Stroke P AP Version 2, 07/11 Stroke P AP

Acute neurological Acutesymptoms neurological symptoms

Obtain GCS Obtain GCS

Positive FAST Positive FAST No assessment No assessment

Yes Yes

Maintain airway Maintain airway Oxygen therapy MaintainOxygen therapySpO2 between Maintain SpO2 between Oxygen therapy 94% to 98% Oxygen therapy (lower94% to range 98% if COPD) (lower range if COPD) Check blood glucose Check blood glucose

Go to Go to BG Glycaemic BG Glycaemic Yes < 4 or > 20 Emergency Yes < 4 or > 20 Emergency mmol/L CPG mmol/L CPG No No

ECG & SpO2 ECGmonitoring & SpO2 monitoring

Onset < 4.5 Onset < 4.5 No hours No hours

Yes Yes

Specialised SpecialisedStroke Unit No Strokeavailable Unit No available Yes Yes

Transport patient to Transporthospital patient with to hospital with Follow local protocol re Specialised Stroke Unit Follow local protocol re Specialised Stroke Unit notifying ED prior to arrival (under local protocol) notifying ED prior to arrival (under local protocol)

F – facial weakness F – facialCan the weakness patient smile?, Has their mouth or eye drooped? Which side? A – armCan weaknessthe patient smile?, Has their mouth or eye drooped? Which side? A – Canarm theweakness patient raise both arms and maintain for 5 seconds? S – Canspeech the patientproblems raise both arms and maintain for 5 seconds? S – Canspeech the patientproblems speak clearly and understand what you say? T – Cantime the to transportpatient speak now clearly if FAST and positive understand what you say? T – time to transport now if FAST positive

Reference ILCORReference Guidelines 2010 ProfILCOR R Boyle,Guidelines 2006, 2010 Mending hearts and brains, Clinical case for change: Report by Prof R Boyle, National Director for Heart Disease and Stroke, NHS AHA,Prof R 2005, Boyle, Part 2006, 9 Adult Mending Stroke, hearts Circulation and brains, 2005; Clinical 112; 111-120 case for change: Report by Prof R Boyle, National Director for Heart Disease and Stroke, NHS A.AHA, Mohd 2005, Nor, Part et al,9 AdultAgreement Stroke, between Circulation ambulance 2005; 112; paramedic- 111-120 and physician- recorded neurological signs with Face Arm Speech Test (FAST) in acuteA. Mohd stroke Nor, patients, et al, Agreement Stroke 004; between 35;1355-1359 ambulance paramedic- and physician- recorded neurological signs with Face Arm Speech Test (FAST) in Jeffreyacute stroke L Saver, patients, et al, PrehospitalStroke 004; neuroprotective35;1355-1359 therapy for acute stroke: results of the field administration of stroke therapy-Magnesium (FAST-MAG) pilotJeffrey trial, L Saver,Stroke et2004; al, Prehospital 35; 106-108 neuroprotective therapy for acute stroke: results of the field administration of stroke therapy-Magnesium (FAST-MAG) Wernerpilot trial, Hacke Stroke MD, 2004; et al, 35; 2008, 106-108 Thrombolysis with Alteplase 3 to 4.5 Hours after Acute Ischemic Stroke, N Engl J Med 2008; 359:1317-29 Werner Hacke MD, et al, 2008, Thrombolysis with Alteplase 3 to 4.5 Hours after Acute Ischemic Stroke, N Engl J Med 2008; 359:1317-29 50 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

4/5.4.29 Version 1, 05/08 Mental Health Emergency EMT P

Behaviour abnormal with previous RMP – Registered Medical Practitioner RPN – Registered Psychiatric Nurse psychiatric history

RMP or RPN Practitioners may not in attendance or have made compel a patient to Yes arrangements for voluntary/ accompany them or assisted admission prevent a patient from leaving an ambulance vehicle No

Co-operate as Obtain a history from patient and or appropriate with If potential to harm self or others bystanders present as appropriate medical or nursing ensure minimum two people team accompany patient in saloon of ambulance at all times Potential Yes to harm self or Transport patient to an others Approved Centre Request control No to inform Gardaí

Reassure patient Explain what is happening at all times Avoid confrontation

Attempt verbal de-escalation

Combative with hallucinations Yes or Paranoia & risk to self or others Request No ALS

Patient agrees No to travel

Yes Request as appropriate - Gardaí Aid to Capacity Evaluation - Medical Practitioner 1. Patient verbalises/ communicates - Mental health team understanding of clinical situation? 2. Patient verbalises/ communicates appreciation of applicable risk? 3. Patient verbalises/ communicates ability to make alternative plan of care? If no to any of the above consider Patient Incapacity

Reference; Reference Guide to the Mental Health Act 2001, Mental Health Commission HSE Mental Health Services

51 Clinical Practice Guidelines

SECTION 4 MEDICAL EMERGENCIES

4/5/6.4.30 Version 1, 05/08 Behavioural Emergency EMT P

Behaviour AP abnormal Obtain a history from patient and or bystanders present as appropriate Practitioners may not compel a patient to accompany them or prevent a patient from leaving an ambulance Indications of Go to vehicle medical cause of Yes appropriate illness CPG

No

Potential Yes to harm self or others Request control No to inform Gardaí

Reassure patient Explain what is happening at all times If potential to harm self or others Avoid confrontation ensure minimum two people accompany patient in saloon of ambulance at all times Attempt verbal de-escalation

Patient agrees No to travel

Injury or illness Yes potentially serious or No likely to cause lasting disability Offer to treat and or Yes transport patient

Inform patient of potential consequences of treatment refusal Treatment only No

Request control Yes to inform Gardaí and or Doctor

Is patient competent to No make informed decision

Yes

Aid to Capacity Evaluation Await arrival of doctor or Advise alternative care options and 1. Patient verbalises/ communicates Gardaí to call ambulance again if there is a understanding of clinical situation? change of mind or 2. Patient verbalises/ communicates receive implied consent appreciation of applicable risk? 3. Patient verbalises/ communicates ability to make alternative plan of care? Document refusal of treatment and or transport to ED If no to any of the above consider Patient Incapacity

Reference: HSE Mental Health Services

52 Clinical Practice Guidelines

SECTION 5 OBSTETRIC EMERGENCIES

5/6.5.1 Version 2, 03/11 Pre-Hospital Emergency Childbirth P AP

Query labour

Take SAMPLE history

If no progress with Patient in labour consider No transporting patient labour Yes

Birth imminent or No travel time too long

Yes Request Ambulance Control to contact GP / midwife/ medical team as required by local policy to come to scene or meet en route Request

ALS Equipment list Cord Clamps Bulb syringe Position mother and prepare Towels equipment for birth Surgical gloves Surgical apron Consider Gauze swaps 10 x 10 cm Umbilical cord scissors Nitrous Oxide Monitor vital signs and BP & Oxygen Clinical waste bag Neonatal BVM Polythene bag Go to Umbilical Cord Cord Yes complication Complications CPG No

Go to Breech Breech Birth Yes birth CPG No

Support baby throughout delivery

No Gestation Yes < 28 weeks

Dry baby and Cover newborn in check ABCs polythene wrap/bag up to neck without drying first

Go to BLS & ALS Baby No Neonate stable CPG Yes Wait at least one Clamp & cut cord minute post birth then clamp cord at 10, 15 & 20 cm from Wrap baby and baby present to mother Cut cord between 15 and 20 cm clamps Go to Mother Primary No stable Survey CPG Yes

If placenta delivers, bring to Reassess hospital with mother Reference: ILCOR Guidelines 2010

53 Clinical Practice Guidelines

SECTION 5 OBSTETRIC EMERGENCIES

5/6.5.2 Version 2, 03/11 Basic & Advanced Life Support – Neonate (< 4 weeks) P AP

From Gestation Childbirth No Initiate mobilisation of 3 to 4 Birth < 28 weeks CPG practitioners / responders on site to assist with cardiac Yes Term arrest management gestation < 4 Weeks old Cover newborn in Amniotic fluid clear Yes polythene wrap/bag up to Breathing or crying neck without drying first Good muscle tone No

Provide warmth Provide warmth Dry baby Position; Clear airway Position; Clear airway Provide warmth (if necessary) (if necessary) Stimulate, reposition Dry, stimulate, reposition

Request

ALS

Assess respirations, CPR 3 : 1 Breathing, HR > 100 & Pink Compressions : Ventilations Apnoeic or HR < 100 heart rate & Use two thumbs encircling colour technique when two practitioners present Breathing, HR > 100 but Cyanotic

Give Supplementary O2

Persistent No Cyanosis

Yes

Provide positive pressure ventilation for 30 sec

Assess HR < 60 HR 60 to 100 Heart Rate

CPR (ratio 3:1) for 30 sec Breathing well, HR > 100

Assess HR 60 to 100 Breathing well, HR > 100 Heart Rate

HR < 60

Consider blood Continue CPR glucose check Epinephrine (1:10 000) 0.01 mg/kg IV/ IO Every 3 to 5 minutes prn Consider pulse oximetry If mother is opiate user consider Naloxone, 0.01 mg/kg IV/IO Or Naloxone, 0.01 mg/kg IM

Consider NaCl (0.9%), 10 mL/kg IV/IO

Reference: ILCOR Guidelines 2010 54 Clinical Practice Guidelines

SECTION 5 OBSTETRIC EMERGENCIES

5/6.5.3 Version 1, 05/08 Haemorrhage in Pregnancy Prior to Delivery P AP

Query pregnant Pregnancy < 24 weeks ≥ 24 weeks Early pregnancy Antepartum haemorrhage haemorrhage

Left lateral tilt

Do not examine abdomen or vagina

Apply absorbent pad to perineum area

Oxygen therapy

Patient is Yes haemodynamically No unstable

Request

ALS

Reassess

Go to Shock CPG

Reference: Sweet, BR, 2000, Mayes’ Midwifery, 12th Edition, Bailleire Tindall

55 Clinical Practice Guidelines

SECTION 5 OBSTETRIC EMERGENCIES

5/6.5.4 05/08 Postpartum Haemorrhage P AP

2nd stage of labour complete

Apply absorbent pad to perineum area

Estimate blood loss Oxygen therapy

Syntometrine, 1 mL IM (if not already administered)

Mother is Yes haemodynamically No unstable

Request

ALS

External massage of the uterus

Check/ ask mother re Reassess multiple births prior to Elevate lower limbs administration of Syntometrine

AP Consider inserting a urinary catheter

Go to Shock CPG

Reference: Sweet, BR, 2000, Mayes’ Midwifery, 12th Edition, Bailleire Tindall

56 Clinical Practice Guidelines

SECTION 5 OBSTETRIC EMERGENCIES

5/6.5.5 P AP Version5/6.5.5 1, 05/08 Umbilical Cord Complications Version 1, 05/08 Umbilical Cord Complications P AP

Cord complicationCord complication Request Request Ambulance Control to contact GP / midwife/ medical team as required by local policy Request Request Ambulance Control to contact GP / to come to scene or meet en route ALS midwife/ medical team as required by local policy ALS to come to scene or meet en route

Oxygen therapy Oxygen therapy

Cord around baby’s neck Cord rupture Prolapsed cord Cord around baby’s neck Cord rupture Prolapsed cord Apply additional Attempt to slip the cord Mother to adopt Applyclamps additional to cord Attemptover the tobaby’s slip the head cord kneeMother chest to adoptposition clamps to cord over the baby’s head knee chest position Apply direct pressure with sterile dressing AP Hold presenting part off Yes Successful Apply direct pressure with sterile dressing AP Holdthe cordpresenting using fingerspart off Yes Successful the cord using fingers No No Maintain cord temperature Clamp cord in two places and Maintainand moisture cord temperature Clampcut between cord in both two clamps places and and moisture cut between both clamps AP Consider inserting an indwelling catheter Ease the cord from into the bladder and run 500 mL of NaCl around the neck AP Consider inserting an indwelling catheter Ease the cord from intointo thethe bladderbladder andand runclamp 500 catheter mL of NaCl around the neck into the bladder and clamp catheter

Go to ChildbirthGo to In labour No CPG Childbirth In labour No CPG Yes Yes

Consider

ConsiderNifedipine, 20 mg, PO Nifedipine, 20 mg, PO

For prolapsed cord pre-alert hospitalFor prolapsed as emergency cord pre-alert caesarean hospitalsection as emergency will be required caesarean section will be required

Reference: Sweet, BR, 2000, Mayes’ Midwifery, 12th Edition, Bailleire Tindall Reference: Sweet,Katz Z BR,et al, 2000, 1988, Mayes’ Management Midwifery, of labor 12th Edition,with umbilical Bailleire cord Tindall prolaps: A 5 year study. Obstet. Gynecol. 72(2): 278-281 KatzDuley, Z LMM,et al, 1988, 2002, Management Clinical Guideline of labor No with1(B), umbilical Tocolytic cord Drugs prolapse: for women A 5 yearin preterm study. labour, Obstet. Royal Gynecol. College 72(2): of Obstetricians278-281 and gynaecologists Duley, LMM, 2002, Clinical Guideline No 1(B), Tocolytic Drugs for women in preterm labour, Royal College of Obstetricians and Gynaecologists

57 Clinical Practice Guidelines

SECTION 5 OBSTETRIC EMERGENCIES

5/6.5.6 Version 1, 05/08 Breech Birth P AP

Breech birth presentation

Request Request Ambulance Control to contact GP / midwife/ medical team as required by local policy ALS to come to scene or meet en route

Oxygen therapy

Mother to adapt the lithotomy position

Support the baby as it emerges – avoid manipulation of the baby’s body

Successful Yes No delivery

No

P

Nape of neck anteriorly visible at No vulva Go to Consider Childbirth Yes Nitrous Oxide CPG & Oxygen Place one hand, palm up, onto baby’s face

Grasp both baby’s ankles in other hand

Rotate baby’s legs in an arc in an upward direction as contractions occur

Successful Yes delivery after 5 contractions

No

Place hand in the vagina with palm towards baby’s face Form a V with fingers on each side of baby’s nose and gently push baby’s head away from vaginal wall

58 Clinical Practice Guidelines

SECTION 6 TRAUMA

4/5/6.6.1 Version 2, 07/11 Burns – Adult EMT P

AP Burn or Cease contact with heat source Scald

Inhalation and/or facial Yes injury Should cool for another Airway management 10 minutes during No packaging and transfer. Caution with hypothermia Go to Respiratory Yes Inadequate distress Ventilations CPG No

Brush off powder & irrigate Commence local Consider humidified chemical burns cooling of burn area Oxygen therapy Follow local expert direction

Remove burned clothing & jewellery (unless stuck) Equipment list Acceptable dressings Burns gel (caution for > 10% TBSA) Dressing/ covering Cling film of burn area Sterile dressing Clean sheet Go to Pain Mgt. Yes Pain > 2/10 CPG No

F: face Caution with the elderly, H: hands Isolated superficial injury circumferential & electrical burns F: feet Yes No F: flexion points (excluding FHFFP) P: perineum

Request TBSA burn No Yes > 10% ALS

ECG & SpO2 monitoring

> 25% TBSA and or time from No Yes injury to ED > 1 hour Consider NaCl (0.9%), 500 mL, IV/IO NaCl (0.9%), 1000 mL, IV/IO

Monitor body temperature

Special Authorisation: Paramedics are authorised to continue P the established infusion in the absence of an Advanced Paramedic or Doctor during transportation

Reference: Allison, K et al, 2004, Consensus on the prehospital approach to burns patient management, Emerg Med J 2004; 21:112-114 Sanders, M, 2001, Paramedic Textbook 2nd Edition, Mosby 59 Clinical Practice Guidelines

SECTION 6 TRAUMA

5/6.6.2 Version 1, 05/08 Crush Injury P AP

Patient Request trapped ALS AcBC Maintain AcBC Airway cervical spine Breathing Oxygen therapy Circulation

Significant Co-ordinate with compression force No rescue personnel on maintained release timing Yes

Consider Mobile Surgical Team (for amputation)

IV access Large bore x 2

Go to Consider Pain Mgt. pain relief CPG

NaCl (0.9%) 20 mL/Kg IV/IO

Prepare all required patient carrying devices and have on standby following extrication ECG & SPO2 monitoring

If possible commence IV fluids prior to release

Apply standard trauma care during and post extrication

Go to appropriate CPG

Special Authorisation: Paramedics are authorised to continue P the established infusion in the absence of an Advanced Paramedic or Doctor during transportation

Reference: Crush Injury Syndrome (# 7102) Patient Care Policy, Alameda County EMS Agency (CA) Crush Injuries, Clinical Practice Manual, Queensland Ambulance Service

60 Clinical Practice Guidelines Clinical Practice Guidelines

SECTION 6 TRAUMA

4/5/6.6.3 EMT P Version4/5/6.6.3 3, 02/14 External Haemorrhage – Adult EMT P Version 3, 02/14 External Haemorrhage – Adult BTEC Open BTEC AP Open AP wound wound

Catastrophic Active bleeding Yes Catastrophic Yes Active bleeding Yes haemorrhage Yes haemorrhage

No No No No Posture P ElevationPosture P Elevation Apply tourniquet if Examination Apply tourniquet if Examination limb injury Request Pressure limb injury Pressure Request ALS consider applying a dressing ALS impregnatedconsider applyingwith haemostatic a dressing agent impregnated with haemostatic agent

Posture EMT Posture Special Authorisation: Elevation EMT Special Authorisation: Elevation EMTs, having completed the Examination EMTs, having completed the Examination BTEC course, may be Pressure BTEC course, may be Pressure privileged by a licensed CPG providerprivileged to by apply a licensed a tourniquet CPG provider onto applyits behalf a tourniquet on its behalf

Apply sterile dressing Apply sterile dressing

Consider ConsiderOxygen therapy Oxygen therapy

Haemorrhage Haemorrhage No controlled No controlled Apply additional Yes Applydressing(s) additional Yes dressing(s)

Haemorrhage Yes Haemorrhage Yes controlled controlled

No No P P Depress proximal Depresspressure pr pointoximal pressure point

Haemorrhage Yes Haemorrhage Yes controlled controlled

No No P P Apply tourniquet Equipment list Apply tourniquet Equipment list Sterile dressing (various sizes) CrepeSterile bandagedressing (various(various sizes) Crepe bandage (various sizes) Go to Conforming bandage (various sizes) Significant Go to Conforming bandage (various sizes) Significant Yes Shock Triangular bandage blood loss Yes Shock Triangular bandage blood loss CPG Trauma tourniquet CPG Trauma tourniquet Dressing impregnated with haemostatic agent No Dressing impregnated with haemostatic agent No

Reference: Reference: ILCOR Guidelines 2010, ILCOR Guidelines 2010, Granville-Chapman J, et al. Pre-hospital haemostatic dressings:A systematic review. Injury (2010), doi: 10.1016/j. injury. 2010.09.037 Granville-Chapman J, et al. Pre-hospital haemostatic dressings:A systematic review. Injury (2010), doi: 10.1016/j. injury. 2010.09.037

61 Clinical Practice Guidelines

SECTION 6 TRAUMA

4/5/6.6.4 Version 2, 05/14 Harness Induced Suspension Trauma EMT P

AP This CPG does not Fall arrested by authorise rescue harness/rope by untrained personnel Caution Patient still No suspended

Yes Personal safety of the Advise patient to move Consider removing a harness Practitioner legs to encourage suspended person from is venous return paramount suspension in the direction of gravity i.e. downwards, so as Elevate lower limbs if to avoid further negative possible during rescue hydrostatic force, however this measure should not otherwise delay rescue. If circulation is compromised Request remove the harness when the patient is safely lowered ALS to the ground

Place patient in a horizontal position as soon as practically If adult cardiac arrest following rescue consider possible Sodium Bicarbonate (8.4%) 50 mEq IV

Monitor BP, SpO2 and ECG

Oxygen therapy to maintain SpO2 > 94%

NaCl (0.9%) 20 mg/Kg aliquots IV to maintain Sys BP > 90 mmHg

Go to appropriate CPG

Patients must be transported to ED following suspension trauma regardless of injury status

Special Authorisation: Paramedics are authorised to continue P the established infusion in the absence of an Advanced Paramedic or Doctor during transportation

Reference: Adish A et al, 2009, Evidence-based review of the current guidance on first aid measures for suspension trauma, Health and Safety Executive (UK) Research report RR708 Australian Resuscitation Council, 2009, Guideline 9.1.5 Harness Suspension Trauma first aid management. Thomassen O et al, Does the horizontal position increase risk of rescue death following suspension trauma?, Emerg Med J 2009;26:896-898 doi:10.1136/ emj.2008.064931

62 Clinical Practice Guidelines Clinical Practice Guidelines

SECTION 6 TRAUMA

5/6.6.5 P AP Version5/6.6.5 2, 01/13 Head Injury – Adult Version 2, 01/13 Head Injury – Adult P AP See Maintain Airway Advanced Head trauma See (ConsiderMaintain Advanced Airway airway) AdvancedAirway Head trauma (Consider Advanced airway) AirwayCPG CPG Oxygen therapy Oxygen therapy Control external haemorrhage Control external haemorrhage

Maintain in-line immobilisation Maintain in-line immobilisation See Consider spinal SpinalSee Considerinjury spinal Spinalinjury injury injuryCPG CPG

SpO2 & ECG monitoring SpO2 & ECG monitoring

Request No GCS ≤ 12 Yes Request No GCS ≤ 12 Yes ALS ALS

No GCS ≤ 8 No GCS ≤ 8 Yes Yes Minimise increases in See IntraMinimise Cranial increases Pressure in PainSee Mgt PainIntra Management Cranial Pressure PainCPG Mgt CPG ControlPain Management nausea & vomiting See 10Controlo upward nausea head & tiltvomiting N&VSee Check10o upward collar head tension tilt CPGN&V Check collar tension CPG

With head injury maintain SBP: See with GCS ≤ 8 at 120 mmHg Avoid hypotension ShockSee With head injury maintain SBP: CPG with GCS ≤> 8 atat 90120 – mmHg 100 mmHg Avoid hypotension Shock with GCS > 8 at 90 – 100 mmHg CPG

See Glycaemic Check blood glucose See EmergencyGlycaemic Check blood glucose EmergencyCPG CPG See Seizures / Patient seizing See ConvulsionsSeizures / Patient seizing ConvulsionsCPG CPG Consider Vacuum Considermattress Vacuum mattress

Equipment list Equipment list Extrication device ExtricationLong board device LongVacuum board mattress VacuumOrthopaedic mattress stretcher OrthopaedicRigid cervical stretcher collar Rigid cervical collar

Reference; th Reference;Mc Swain, N, 2011, PHTLS Prehospital Trauma Life Support 7 Edition, Mosby Mc Swain, N, 2011, PHTLS Prehospital Trauma Life Support 7th Edition, Mosby 63 Clinical Practice Guidelines

SECTION 6 TRAUMA

4/5/6.6.6 Version 1, 12/13 Heat-Related Emergency – Adult EMT P

AP Collapse from heat- related condition

Remove/ protect from hot environment (providing it is safe to do so)

Yes Alert No

Mild Hyperthermia Give cool fluids to (heat stress) Maintain airway drink

Check blood Exercise-related dehydration glucose should be treated with oral fluids. (caution with over hydration with water) Cool patient Do not over cool Cooling may be achieved by: Removing clothing Fanning Moderate SpO2 & ECG Tepid sponging Hyperthermia monitor Ice packs (Heat exhaustion)

Consider

ALS

Severe Consider Hyperthermia (Heat stroke) > 40oC NaCl (0.9%) 1 L IV

Elevate oedematous limbs

P Special Authorisation: Paramedics are authorised to continue the established infusion in the absence of an Advanced Paramedic or Doctor during transportation

Reference: ILCOR Guidelines 2010, European Resuscitation Guidelines 2010. RFDS, 2011, Primary Clinical Care Manual 64 Clinical Practice Guidelines Clinical Practice Guidelines

SECTION 6 TRAUMA

4/5/6.6.7 Version 4, 02/14 Limb Injury – Adult EMT P

Limb injury AP

Consider Go to Establish need for pain relief Pain CPG ALS

Expose and examine limb

Dress open wounds Equipment list Traction splint Box splint Provide manual stabilisation for Frac straps injured limb Triangular bandages Vacuum splints Long board Orthopaedic stretcher Check CSMs distal to Cold packs injury site Elastic bandages Pelvic splinting device

Injury type

Fracture Fractured femur Soft tissue injury Dislocation

Isolated lateral Neck of Mid shaft Yes Other dislocation of patella femur of femur

No Request > 20 min Yes Consider to facility ALS Paramedic No

Consider NaCl (0.9%), 250 mL IV

P Rest AP Splint/support Reduce Apply Ice Apply traction in position dislocation and appropriate Compression splint found apply splint splinting device Elevation

Recheck CSMs

Contraindications for application of traction splint 1 # pelvis 2 # knee 3 Partial amputation For a limb-threatening injury 4 Injuries to lower third of lower leg treat as an emergency and 5 Hip injury that prohibits normal alignment pre alert ED

Reference: An algorithm guiding the evaluation and treatment of acute primary patellar dislocations, Mehta VM et al. Sports Med Arthrosc. 2007 Jun;15(2):78-81

65 Clinical Practice Guidelines

SECTION 6 TRAUMA

5/6.6.8 Version 3, 12/13 Shock from Blood Loss (trauma) – Adult P AP

Clinical signs of shock

Control external haemorrhage

Oxygen therapy

Request

ALS

Patient trapped No

Yes

NaCl (0.9%), 500 mL IV/IO

Suspected significant No With polytrauma internal/ external consider application haemorrhage of a pelvic splint Yes

Tranexamic acid 1 g IV/IO (in 100 mL NaCl)

Head injury Yes No with GCS ≤ 8

NaCl (0.9%), 250 mL IV/IO aliquots NaCl (0.9%), 250 mL IV/IO aliquots to maintain palpable radial pulse to maintain SBP 120 mmHg (SBP 90 - 100 mmHg)

Maintain normo-temperature

Continue fluid therapy until handover at ED

P Special Authorisation: Paramedics are authorised to continue the established infusion in the absence of an Advanced Paramedic or Doctor during transportation

Reference: Gruen, R. L. and M. C. Reade (2012). "Administer tranexamic acid early to injured patients at risk of substantial bleeding." BMJ 345: e7133 66 Clinical Practice Guidelines Clinical Practice Guidelines

SECTION 6 TRAUMA

5/6.6.9 Version 2, 07/11 Spinal Immobilisation – Adult P AP 5/6.6.9 Version 2, 07/11 Spinal Immobilisation – Adult P AP Trauma Initial indications for Use clinical Trauma spinal immobilisation Do not forcibly restrain a judgement Initial indications for patient that is combative UseIf in clinicaldoubt, spinal immobilisation Do not forcibly restrain a judgement Return head to neutral position unless on patient that is combative immobilise movement there is Increase in If in doubt, Pain,Return Resistance head to neutral or Neurological position unless symptoms on immobilise movement there is Increase in Pain, Resistance or Neurological symptoms Remove helmet (if worn) Remove helmet (if worn) Dangerous mechanism include; Neck or Fall ≥ 1 meter/ 5 steps back pain or DangerousAxial load to mechanismhead include; No midlineNeck spinal or FallMVC ≥ >1 100metre/ km/hr, 5 steps rollover or ejection backtenderness pain or AxialATV collisionload to head No midline spinal MVCBicycle > 100collision km/hr, rollover or ejection tendernessYes ATVPedestrian collision v vehicle Dangerous Bicycle collision mechanism of Pedestrian v vehicle Yes injuryDangerous or significant No mechanismdistracting of injury orinjury significant No distracting Are all of the factors listed present; injuryYes GCS = 15 AreCommunication all of the factors effective listed (not present; intoxicated with alcohol or drugs) Yes GCSAbsence = 15 of numbness, tingling or weakness in extremities Yes CommunicationPresence of low effectiverisk factors (not which intoxicated allow safe with assessmentalcohol or drugs) of range of motion AbsencePatient voluntarily of numbness, able totingling rotate or neck weakness 45o left in& extremitiesright without pain Yes PresencePatient can of walk low riskwithout factors pain which allow safe assessment of range of motion o Patient voluntarily able to rotate neckNo 45 left & right without pain Patient can walk without pain No

Life Immobilisation Yes No Threatening may not be Life Immobilisationindicated Yes NoApply cervical collar Threatening may not be indicated Apply cervical collar

Rapid extrication with long Patient in Go to board and cervical collar Yes sitting position appropriate Rapid extrication with long Patient in GoCPG to board and cervical collar Yes sittingNo position Use extrication device appropriate CPG No Use extrication device

Load onto vacuum mattress or long board Load onto vacuum mattress or long board Low risk factors Simple rear end MVC Consider Vacuum Low(excluding risk factors push into mattress Simpleoncoming rear traffic end orMVC hit by Consider Vacuum (excludingbus or truck) push into mattress oncoming traffic or hit by bus or truck)

Equipment list

ExtricationEquipment device list Long board ExtricationVacuum mattress device LongOrthopaedic board stretcher VacuumRigid cervical mattress collar Orthopaedic stretcher Rigid cervical collar Reference: Vaillancourt, Christian et al, 2009, Ann Emerg Med. 2009 Nov; 54(5): 663-671.e1. Ppub 2009 Apr 24

Reference: Vaillancourt, Christian et al, 2009, Ann Emerg Med. 2009 Nov; 54(5): 663-671.e1. Ppub 2009 Apr 24 67 Clinical Practice Guidelines

SECTION 6 TRAUMA

4/5/6.6.10 Version 2, 02/14 Submersion Incident EMT P

AP Submerged Request in liquid ALS Remove patient from liquid (Provided it is safe to do so)

Remove horizontally if possible (consider C-spine injury) Spinal injury indicators Ventilations may be History of; commenced while the Complete primary survey - diving patient is still in water (Commence CPR if appropriate) - trauma by trained rescuers - water slide use - alcohol intoxication Go to Adequate Inadequate No ventilations Ventilations CPG Yes Higher pressure may be Oxygen therapy required for ventilation because of poor compliance resulting from

SpO2 & ECG monitoring pulmonary oedema

Indications Yes of respiratory distress

No

Monitor Pulse, If bronchospasm consider Respirations & BP Salbutamol ≥ 5 years 5 mg NEB < 5 years 2.5 mg NEB Go to Patient is Yes Hypothermia hypothermic CPG

No

Check blood glucose

Do not delay on site Transport to ED for Continue algorithm en route investigation of secondary drowning insult

Reference: Golden, F & Tipton M, 2002, Essentials of Sea Survival, Human Kinetics Verie, M, 2007, Near Drowning, E medicine, www.emedicine.com/ped/topic20570.htm Shepherd, S, 2005, Submersion Injury, Near Drowning, E Medicine, www.emedicine.com/emerg/topic744.htm AHA, 2005, Part 10.3: Drowning, Circulation 2005:112;133-135 Soar, J et al, 2005, European Resuscitation Council Guidelines for Resuscitation 2005, Section 7. Cardiac arrest in special circumstances, Resuscitation (2005) 6751, S135-S170

68 Clinical Practice Guidelines Clinical Practice Guidelines

SECTION 6 TRAUMA

5/6.6.11 Version 1, 05/08 Traumatic Cardiac Arrest – Adult P AP

EMS Unwitnessed EMS Witnessed Traumatic Arrest Traumatic Arrest

Go to Apnoeic, appropriate No Pulseless and CPG Asystolic

Yes

Blunt trauma No

Yes

<18 years Hypothermia Commence Drowning Yes to any Lightning strike CPR and ALS Electrical injury

No to all Request

ALS

Low energy Yes incident

Rapid transport towards ALS No

Patient responds No to BLS or ALS Yes provision within 15 min

Consider ceasing resuscitation

Go to Go to Recognition Asystole of Death Decision CPG Tree CPG

Reference: Hopson, L et al, 2003, Guidelines for withholding or termination of resuscitation in prehospital traumatic cardiac arrest, Position paper for National Association of EMS Physicians, Prehospital Emergency Care, Vol 7 p141-146

69 Clinical Practice Guidelines

SECTION 7 PAEDIATRIC EMERGENCIES

4/5/6.7.1 Version 4, 12/13 Primary Survey Medical – Paediatric (≤ 15 Years) EMT P

AP Medical Take standard infection control precautions issue

Consider pre-arrival information The primary survey is focused on establishing the patien t’s clinical status and only applying interventions when they are essential to maintain life. Scene safety It should be completed within one Scene survey Paediatric Assessment Triangle minute of arrival on scene. Scene situation

Paediatric Assessment Triangle

Work of Appearance Breathing Suction, Head tilt/ A OPA No Airway patent & Circulation chin lift NPA protected to skin P Ref: Pediatric Education for Prehospital Professionals Yes

Give 5 B Consider Ventilations Adequate No Oxygen therapy ventilation Oxygen therapy Yes

C Pulse < 60 & signs Yes of poor perfusion

No

AVPU assessment

Go to Secondary Life Clinical status decision Non serious threatening or life threat Survey CPG

Serious not life threat

If child protection concerns are present Request

ALS Report findings as per Children First guidelines to ED staff and line manager in a confidential manner Go to appropriate CPG Normal ranges Age Pulse Respirations Infant 100 – 160 30 – 60 Toddler 90 – 150 24 – 40 Pre school 80 – 140 22 – 34 School age 70 – 120 18 – 30 Reference: ILCOR Guidelines 2010, American Academy of Pediatrics, 2000, Pediatric Education for Prehospital Professionals Department of Children and Youth A airs, 2011, Children Firs t: National Guidance for the Protection and Welfare of Children

70 Clinical Practice Guidelines

SECTION 7 PAEDIATRIC EMERGENCIES

4/5/6.7.2 Primary Survey Trauma – Paediatric (≤ 15 years) Version 4, 12/13 EMT P

Trauma Take standard infection control precautions AP

Consider pre-arrival information Paediatric Assessment Triangle The primary survey is focused on establishing the patient’s clinical status Scene safety and only applying interventions when Scene survey they are essential to maintain life. Scene situation It should be completed within one minute of arrival on scene. Work of Appearance Breathing Paediatric Assessment Triangle

Circulation Control catastrophic to skin external haemorrhage Ref: Pediatric Education for Prehospital Professionals

Mechanism of C-spine No injury suggestive Yes control of spinal injury

Suction, A Jaw thrust OPA No Airway patent & (Head tilt/ chin lift) P NPA(> 1 year) protected Yes

Give 5 B Consider Ventilations No Adequate Oxygen therapy ventilation Oxygen therapy Yes

C Pulse < 60 & signs Yes of poor perfusion

No If child protection concerns AVPU assessment are present

Expose & check obvious injuries Report findings as per Children First guidelines to ED staff and line manager in a confidential manner Treat life-threatening injuries only

Go to Life Non serious Secondary Clinical status decision threatening or life threat Survey CPG

Serious not life threat Normal ranges Go to Request Age Pulse Respirations appropriate Infant 100 – 160 30 – 60 CPG ALS Toddler 90 – 150 24 – 40 Pre school 80 – 140 22 – 34 School age 70 – 120 18 – 30 Reference: ILCOR Guidelines 2010, American Academy of Pediatrics, 2000, Pediatric Education for Prehospital Professionals Department of Children and Youth Affairs, 2011, Children First: National Guidance for the Protection and Welfare of Children 71 Clinical Practice Guidelines

SECTION 7 PAEDIATRIC EMERGENCIES

4/5/6.7.4 Version 3, 12/13 Secondary Survey – Paediatric ( ≤ 15 years) EMT P 4/5/6.7.4 Version 3, 12/13 Secondary Survey – Paediatric ( ≤ 15 years) EMT P AP Primary AP Survey Primary Survey Make appropriate contact Use age appropriate with patient and or guardian language for patient Make appropriateif possible contact Use age appropriate with patient and or guardian language for patient if possible Identify presenting complaint and exact chronology from the time the Identifypatient waspresenting last well complaint and Children and adolescents should exactCheck chronology for normal frompatterns the oftime the always be examined with a chaperone patient was -last feeding well Children(usually a and parent) adolescents where possible should Check for normal- toilet patterns of always be examined with a chaperone - feedingsleeping (usually a parent) where possible - interactiontoilet with guardian - sleeping - interaction with guardian Estimated weight Neonate = 3.5 Kg Identify patient’s weight Six monthsEstimated = 6 Kg weight NeonateOne to five = 3.5years Kg = (age x 2) + 8 Kg Identify patient’s weight SixGreater months than = 56 yearsKg = (age x 3) + 7 Kg Head to toe examination One to five years = (age x 2) + 8 Kg Go to Identify positive findings Observing for Greater than 5 years = (age x 3) + 7 Kg appropriate and initiate care Head- to pyrexia toe examination GoCPG to Identifymanagement positive findings Observing for- rash appropriate and initiate care - pyrexiapain CPG management - rashtenderness - bruisingpain - woundstenderness - bruisingfractures - medicalwounds alert jewellery - fractures - medical alert jewellery Normal ranges Age Pulse Respirations Re-check vital NormalInfant ranges 100 – 160 30 – 60 signs AgeToddler Pulse 90 – 150 Respirations 24 – 40 Recheck vital InfantPre school 100 80 – 160140 3022 – 6034 signs ToddlerSchool age 9070 – 150120 2418 – 4030 Check for current Pre school 80 – 140 22 – 34 medications School age 70 – 120 18 – 30 Check for current medications

If child protection concerns are present If child protection concerns are present

Report findings as per Children First guidelines to ReportED staff findings and line as manager per in a Childrenconfidential First manner guidelines to ED staff and line manager in a confidential manner Reference: Miall, Lawrence et al, 2003, Paediatrics at a Glance, Blackwell Publishing Reference:Department of Children and Youth Affairs, 2011, Children First: National Guidance for the protection and Welfare of Children Miall,Luscombe, Lawrence M et etal al,2010, 2003, BMJ, Paediatr Weightics estimation at a Glance, in paediatrics:Blackwell Publishing a comparison of the APLS formula and the formula ‘Weightﾼ3(age)+7’ Department of Children and Youth Affairs, 2011, Children First: National Guidance for the Protection and Welfare of Children Luscombe, M et al 2010, BMJ, Weight estimation in paediatrics: a comparison of the APLS formula and the formula ‘Weightﾼ3(age)+7’ 72 Clinical Practice Guidelines

SECTION 7 PAEDIATRIC EMERGENCIES

4/5/6.7.5 Version 6, 02/14 Pain Management – Paediatric (≤ 15 years) EMT P

AP Pain

Pain assessment recommendation < 5 years use FLACC scale Pain assessment Practitioners, depending on his/ 5 – 7 years use Wong Baker scale her scope of practice, may ≥ 8 years use analogue pain scale make a clinical judgement and commence pain relief on a Administer pain medication based on Analogue Pain Scale higher rung of the pain ladder. pain assessment and pain ladder 0 = no pain……..10 = unbearable recommendations

Yes or best achievable Adequate relief of pain

No Go back to Reassess and move originating up the pain ladder if CPG appropriate

N g/Kg I 0015 m nyl 0. Fenta cg/Kg) Fentanyl IN & (1.5 m n Request t x 1 pr Morphine PO Repea d / or for ≥ 1 year ALS An old only g PO mg/K ne 0.3 Morphi 0 mg Severe pain Max 1 (≥ 7 on pain scale) or Repeat Fentanyl Kg IV IN, once only, at 05 mg/ ne 0. not < 10 min after orphi mg/Kg M x 0.1 O Ma initial dose. /Kg P 0 mg or mol 2 d / ceta an , Para or ygen Consider d / & Ox an g PO xide Repeat Morphine Paramedic mg/K us O 10 Nitro inh IV at not < 2 min rofen Ibup intervals prn to Moderate pain Max: 0.1 mg/kg IV or sider g (4 to 6 on pain scale) and / Con 1 mg/K etron 0. ) ndans 4 mg O ly (Max en, slow Oxyg IV ide & us Ox Nitro inh

PO g/Kg 20 m amol entions racet terv Pa cal in Mild pain ologi rmac pha dder (1 to 3 on pain scale) - in La er non ric Pa oth ediat ider C Pa Cons PHEC

Decisions to give analgesia must be based on clinical assessment and not directly on a linear scale

Reference: World Health Organization, Pain Ladder 73 Clinical Practice Guidelines

SECTION 7 PAEDIATRIC EMERGENCIES

5.7.10 Version 1, 03/14 Advanced Airway Management – Paediatric (≥ 8 years) P

Prolonged CPR

Ventilations Consider No maintained FBAO

Yes

Minimum interruptions of chest compressions. Supraglottic airway insertion

Maximum hands off time 10 seconds.

Successful Yes

No

Ensure CO2 detection Revert to basic airway device in ventilation Maintain adequate management circuit ventilation and oxygenation throughout procedures Check placement of advanced airway after each patient movement or if any patient deterioration

Continue ventilation and oxygenation

Go to appropriate CPG

Following successful Advanced Airway management:- i) Ventilate at 12 to 20 per minute. ii) Unsynchronised chest compressions continuous at 100 to 120 per minute

Reference: ILCOR Guidelines 2010, Paediatric basic and advanced life support 74 Clinical Practice Guidelines

SECTION 7 PAEDIATRIC EMERGENCIES

4/5/6.7.11 Version 3, 03/14 Inadequate Ventilations – Paediatric (≤ 15 years) EMT P

AP Respiratory Airway Go to patent & No Airway difficulty protected CPG

Yes P Consider Raised ETCO2 + reduced SpO2: Check SpO2 ETCO 2 Consider assisted ventilation

Raised ETCO2 + normal SpO2: 100% O2 initially Oxygen therapy Encourage deep breaths Titrate O2 to standard as clinical condition improves

Request

ALS

Patient assessment

Consider positive pressure ventilations (12 to 20 per minute) via BVM

Brain insult Respiratory failure Substance intake Other

If suspected narcotic OD Consider Go to Respiratory assessment Naloxone, 0.01 mg/Kg IV/IO Consider pain, posture & Head neuromuscular disorders injury Or CPG Naloxone, 0.01 mg/Kg IM/SC

Or Naloxone, 0.02 mg/Kg IN

Bronchospasm/ Asymmetrical Crepitations Other known asthma breath sounds

Go to Go to Consider shock, cardiac/ Go to neurological/ systemic Asthma Anaphylaxis Sepsis CPG CPG illness, pain or CPG psychological upset

Consider collapse, consolidation & fluid

Tension Yes Pneumothorax No suspected AP Needle decompression

75 Clinical Practice Guidelines

SECTION 7 PAEDIATRIC EMERGENCIES

4/5/6.7.12 Version 2, 05/14 Asthma – Paediatric (≤ 15 years) EMT P

Asthma/ AP bronchospasm Assess and maintain airway

Respiratory assessment

< 5 years Salbutamol 2.5 mg NEB ≥ 5 years Salbutamol 5 mg, NEB If no improvement Salbutamol Mild Asthma OR aerosol, 0.1 mg may be repeated; Salbutamol for < 5 year olds up to 3 times, (0.1 mg) metered aerosol for ≥ 5 year olds up to 5 times, as required

Resolved/ Yes improved

No

ECG & SpO2 monitoring

Oxygen therapy

Request

ALS

< 5 years Salbutamol 2.5 mg NEB ≥ 5 years Salbutamol 5 mg, NEB OR Ipratropium bromide Moderate Asthma < 12 years 0.25 mg NEB ≥ 12 years 0.5 mg NEB & age specific Salbutamol NEB mixed

Resolved/ Yes improved

No

Salbutamol, age-specific dose, NEB

Resolved/ Yes improved

No

Hydrocortisone (in 100 mL NaCl) Severe Asthma < 1 year 25 mg IV 1 – 5 years 50 mg IV > 5 years 100 mg IV

Salbutamol, age-specific dose, NEB

Resolved/ Yes improved

No

Salbutamol, age-specific dose, NEB Life-threatening Every 5 minutes prn Asthma

Reference: HSE National Asthma Programme 2012, Emergency Asthma Guidelines, British Thoracic Society, 2008, British Guidelines on the Management of Asthma, a national clinical guideline 76 Clinical Practice Guidelines

SECTION 7 PAEDIATRIC EMERGENCIES

4/5/6.7.13 Version 2, 12/13 Stridor – Paediatric (≤ 15 years) EMT P

AP

Stridor

Consider FBAO

Assess & maintain airway

Croup or epiglottitis Yes suspected

No Do not insert anything into the mouth

Do not distress Transport in position of comfort

Humidified O2 – as high a concentration as tolerated Oxygen therapy

ECG & SpO2 monitoring

77 Clinical Practice Guidelines

SECTION 7 PAEDIATRIC EMERGENCIES

4/5/6.7.20 Version 2, 12/13 Basic Life Support – Paediatric (≤ 15 Years) EMT P

AP Cardiac arrest or Initiate mobilisation of 3 to 4 practitioners / responders pulse < 60 per minute with signs of poor perfusion on site to assist with cardiac arrest management Give 5 rescue ventilations < 8 years use paediatric Oxygen therapy defibrillation system (if not available use adult pads)

Request

ALS One rescuer CPR 30 : 2 Two rescuer CPR 15 : 2 Compressions : Ventilations Minimum interruptions of chest compressions. Commence chest Compressions Continue CPR (30:2) until defibrillator is attached Chest compressions Maximum hands off time Rate: 100 to 120/ min 1 10 seconds. Depth: /3 depth of chest Child; two hands Small child; one hand Infant (< 1); two fingers

Yes < 8 years No

AP With two rescuer CPR use Change defibrillator to two thumb-encircling hand manual mode chest compression for infants Apply paediatric system Apply adult defibrillation P Consider changing AED pads pads defibrillator to manual mode

Shockable Assess Non - Shockable Continue VF or pulseless VT Rhythm Asystole or PEA CPR while defibrillator is charging Give 1 shock

Immediately resume CPR x 2 minutes

Rhythm check *

Go to VF / Go to Post Pulseless VT VF/ VT ROSC Resuscitation CPG Care CPG

Asystole / PEA

Go to Asystole / PEA CPG

Infant AED It is extremely unlikely to ever have to defibrillate a child less than 1 year old. Nevertheless, if this were to occur the * +/- Pulse check: pulse check after 2 minutes of CPR if potentially perfusing rhythm approach would be the same as for a child over the age of 1. The only likely difference being, the need to place the defibrillation pads anterior (front) and posterior (back), Reference: ILCOR Guidelines 2010 because of the infant’s small size.

78 Clinical Practice Guidelines

SECTION 7 PAEDIATRIC EMERGENCIES

4/5.7.21 EMT P Version 2, 12/13 Foreign Body Airway Obstruction – Paediatric (≤ 15 years)

Are you FBAO choking?

Severe FBAO Mild (ineffective cough) Severity (effective cough)

No Conscious Yes

1 to 5 back blows followed by 1 to 5 thrusts Encourage cough (child – abdominal thrusts) (infant – chest thrusts) as indicated Yes

Request Breathing No Conscious No Effective Yes Yes adequately ALS

No Open mouth and look for object If visible one attempt to Positive pressure remove it ventilations (12 to 20/ min)

Attempt 5 Rescue Breaths Consider

Oxygen therapy

One cycle of CPR

Effective Yes

No

One cycle of CPR

Effective Yes

No Oxygen therapy

Go to BLS Paediatric CPG

After each cycle of CPR open mouth and look for object. If visible attempt once to remove it

79 Clinical Practice Guidelines

SECTION 7 PAEDIATRIC EMERGENCIES

4/5/6.7.22 Version 3, 12/13 VF or Pulseless VT – Paediatric (≤ 15 years) EMT P

AP From BLS VF or VT Paediatric arrest CPG < 8 years use paediatric defibrillation system (if not available use adult pads) AP Immediate IO access if IV not immediately accessible Refractory VF/VT post Epinephrine

Amiodarone, 5 mg/kg, IV/IO

Go to Post Resuscitation ROSC Defibrillate Care CPG Yes (4 joules/Kg)

No VF/VT

Go to AP Asystole / Asystole/PEA Advanced airway PEA CPG management

Rhythm Check blood glucose check * Epinephrine (1:10 000), 0.01 mg/kg IV/IO Repeat every 3 to 5 minutes prn

Initial Epinephrine between 2nd and 4th shock

Transport to ED if no change after 10 minutes resuscitation If no ALS available

With CPR ongoing maximum hands off time 10 seconds Continue CPR during charging Drive smoothly Following successful Advanced Airway management:- i) Ventilate at 12 to 20 per minute. ii) Unsynchronised chest Clinical leader to compressions continuous at 100 Consider causes and treat as monitor quality appropriate: to 120 per minute Hydrogen ion acidosis of CPR Hyper/ hypokalaemia Hypothermia AP Consider use Hypovolaemia of waveform Hypoxia capnography Thrombosis – pulmonary Tension pneumothorax Thrombus – coronary Tamponade – cardiac Initiate mobilisation of 3 to 4 Toxins practitioners / responders Trauma on site to assist with cardiac arrest management * +/- Pulse check: pulse check after 2 minutes of CPR if potentially perfusing rhythm

Reference: ILCOR Guidelines 2010

80 Clinical Practice Guidelines

SECTION 7 PAEDIATRIC EMERGENCIES

4/5/6.7.23 Version 3, 12/13 Asystole/PEA – Paediatric ( ≤ 15 years) EMT P

AP From BLS Asystole/ PEA Paediatric CPG arrest Initiate mobilisation of 3 to 4 practitioners / responders AP on site to assist with cardiac arrest management Immediate IO access if IV not immediately accessible

Go to Post Resuscitation ROSC Care CPG Yes Asystole/ No PEA

Go to VF / Pulseless VT VF/VT AP CPG Rhythm Advanced airway check * Epinephrine (1:10 000), 0.01 mg/kg IV/IO management Repeat every 3 to 5 minutes prn Check blood glucose

Transport to ED if no change after 10 minutes resuscitation If no ALS available

With CPR ongoing maximum hands off time 10 seconds Drive smoothly

Clinical leader to monitor quality of CPR

Consider causes and treat as appropriate: Following successful Advanced Hydrogen ion acidosis Airway management:- Hyper/ hypokalaemia i) Ventilate at 12 to 20 per minute. Hypothermia ii) Unsynchronised chest Hypovolaemia compressions continuous at 100 Hypoxia to 120 per minute Thrombosis – pulmonary Tension pneumothorax Thrombus – coronary Consider fluid challenge Tamponade – cardiac AP Toxins NaCl (0.9%) 20 mL/Kg IV/IO Consider use Trauma of waveform capnography

* +/- Pulse check: pulse check after 2 minutes of CPR if potentially perfusing rhythm

Reference: ILCOR Guidelines 2010

81 Clinical Practice Guidelines

SECTION 7 PAEDIATRIC EMERGENCIES

4/5/6.7.24 Version 3, 10/13 Symptomatic Bradycardia – Paediatric (≤ 15 years) EMT P

AP Symptomatic Bradycardia Oxygen therapy

Initiate mobilisation of 3 to 4 practitioners / responders Yes Hypoxia on site to assist with cardiac arrest management Consider positive No pressure ventilations (12 to 20/ min) Collective signs of inadequate perfusion Tachypnoea Diminished/absent peripheral pulses Delayed capillary refill Cool extremities, mottling AP Unresponsive Request Immediate IO access if IV ALS not immediately accessible

Unresponsive Signs of Inadequate No perfusion & HR < 60

Yes

CPR

ECG & SpO2 monitoring

NaCl (0.9%) 20 mL/Kg IV/IO

Check blood glucose Reassess

Epinephrine (1:10 000) 0.01 mg/kg (10 mcg/kg) IV/ IO Every 3 – 5 min prn

Persistent No bradycardia

Yes

Continue CPR

If no ALS available

Reference: International Liaison Committee on Resuscitation, 2010, Part 6: Paediatric basic and advanced life support, Resuscitation (2005) 67, 271 – 291

82 Clinical Practice Guidelines

SECTION 7 PAEDIATRIC EMERGENCIES

5/6.7.25 Version 2, 12/13 Post-Resuscitation Care – Paediatric (≤ 15 years) P AP

Return of Spontaneous Circulation Maintain Oxygen therapy Titrate O2 to 96% - 98%

Request

ALS

Initiate mobilisation of 3 to 4 practitioners / responders Unresponsive No on site to assist with cardiac arrest management Yes

Adequate No ventilation Positive pressure ventilations Max 12 to 20 per minute Yes For active cooling place cold packs at arm pit, groin & abdomen

Commence active cooling

Maintain patient at rest

ECG & SpO2 monitoring

Monitor blood pressure and GCS

Check blood glucose

Monitor vital signs

Transport quietly and smoothly

Consider causes and treat as appropriate: Hydrogen ion acidosis Hyper/ hypokalaemia Hypothermia If persistent poor perfusion Hypovolaemia consider Hypoxia NaCl (0.9%) 20 mL/Kg IV/IO Thrombosis – pulmonary Tension pneumothorax Thrombus – coronary Tamponade – cardiac Equipment list Toxins Trauma Cold packs

Reference: ILCOR Guidelines 2010 83 Clinical Practice Guidelines

SECTION 7 PAEDIATRIC EMERGENCIES 5/6.7.30 Version 1, 12/13 Adrenal Insufficiency – Paediatric (≤ 15 years) P AP 5/6.7.30 Version 1, 12/13 Adrenal Insufficiency – Paediatric (≤ 15 years) P AP Diagnosed with Addison’s disease or Adrenal insufficiency Diagnosed with Addison’s disease or Adrenal insufficiency Recent illness or No injury Recent illnYeess or No injury

Yes Check blood glucose

Check blood glucose

Poor perfusion No

Poor Yeperfusions No

RequestYes

ALS Request Consider HydrocortisoneALS IV Hydrocortisone IM (in 100 mL NaCl) 6 mth ≤ 5 years: 50 mg Consider 6 mth ≤ 5 years: 50 mg > 5 years: 100 mg > 5Hydrocortisone years: 100 IV mg Hydrocortisone IM (in 100 mL NaCl) if IV not available 6 mth ≤ 5 years: 50 mg 6 mth ≤ 5 years: 50 mg > 5 years: 100 mg > 5 years: 100 mg if IV not available Reassess

Reassess

NaCl (0.9%) 20 mL/Kg IV

NaCl (0.9%) 20 mL/Kg IV

P Special Authorisation: Paramedics are authorised to continue the established infusion in the P Specialabsence Authorisation: of an Advanced Paramedic or Doctor during transportation Paramedics are authorised to continue the established infusion in the absence of an Advanced Paramedic or Doctor during transportation

Reference: Antal, Z. and P. Zhou (2009). "Addison disease." Pediatr Rev 30(12): 491-493

Reference: Antal, Z. and P. Zhou (2009). "Addison disease." Pediatr Rev 30(12): 491-493 84 Clinical Practice Guidelines

SECTION 7 PAEDIATRIC EMERGENCIES

5/6.7.31 Version 3, 12/13 Allergic Reaction/Anaphylaxis – Paediatric (≤ 15 years) P AP

Allergic reaction Oxygen therapy Severe/ Mild Moderate Anaphylaxis

Epinephrine administered pre No arrival? (within 5 minutes) Epinephrine (1:1 000) IM < 6 months: 0.05 mg (50 mcg) IM 6 months to 5 years: 0.125 mg (125 mcg) IM Yes 6 to 8 years: 0.25 mg (250 mcg) IM Monitor > 8 years: 0.5 mg (500 mcg) IM reaction

Request Repeat Epinephrine Salbutamol NEB may be substituted with at 5 minute intervals Salbutamol aerosol 0.1 mg. ALS if no improvement If no improvement Salbutamol may be repeated; for < 5 year olds up to 3 times, for ≥ 5 year olds up to 5 times, prn Reassess

If bronchospasm consider nebuliser Reoccurs / Salbutamol NEB No deteriorates / < 5 yrs: 2.5 mg no improvement 5 yrs: 5 mg

Yes

Reassess

ECG & SpO2 ECG & SpO2 monitor monitor

Request Epinephrine (1:1 000) IM Deteriorates Yes See age-related doses above ALS

No NaCl (0.9%), 20 mL/Kg IV/IO bolus Repeat by one prn

If bronchospasm consider nebuliser Salbutamol NEB See age-related doses above

Severe or recurrent reactions Yes and or patients with Hydrocortisone asthma (infusion in 100 mL NaCl) < 1 yr 25 mg IV or IM No 1-5 yrs 50 mg IV or IM > 5 yrs 100 mg IV or IM

Mild Urticaria and or angio oedema Special Authorisation: Paramedics are authorised to continue P the established infusion in the absence Severe Moderate Moderate symptoms + Mild symptoms + simple of an Advanced Paramedic or Doctor haemodynamic and or bronchospasm during transportation respiratory compromise

85 Clinical Practice Guidelines

SECTION 7 PAEDIATRIC EMERGENCIES

5/6.7.32 Version 3, 12/13 Glycaemic Emergency – Paediatric (≤ 15 years) P AP

Abnormal blood glucose level

< 4 mmol/L Blood Glucose 11 to 20 mmol/L

Consider Glucose gel > 20 mmol/L ≤ 8 years 5-10 g Buccal > 8 years 10-20 g Buccal

Request

ALS

No Yes

IV access

Glucagon ≤ 8 years 0.5 mg IM Dextrose 10% 5 mL/Kg IV/IO bolus > 8 years 1 mg IM Repeat x 1 prn

Consider Reassess No Dehydration ALS Yes

NaCl (0.9%) 10 mL/Kg IV/IO bolus

Special Authorisation: Paramedics are authorised to continue P the established infusion in the absence of an Advanced Paramedic or Doctor during transportation

Reference: Dehydration- Paramedic Textbook 2nd E p 1229

86 Clinical Practice Guidelines

SECTION 7 PAEDIATRIC EMERGENCIES

5/6.7.33 Version 3, 02/14 Seizure/Convulsion – Paediatric (≤ 15 years) P AP

Seizure / convulsion

Consider other causes of seizures Protect from harm Meningitis Head injury Hypoglycaemia Oxygen therapy Fever Poisons Alcohol/drug withdrawal

Seizing currently Seizure status Post seizure

Request Consider

ALS ALS

No Yes

IV access Midazolam 0.1 mg/Kg IV/IO Midazolam buccal Repeat by one prn < 1 year: 2.5 mg Or 1 year to < 5 years; 5 mg 5 years to < 10 years: 7.5 mg Diazepam 0.1 mg/Kg IV/IO ≥ 10 years: 10 mg Repeat by one prn Repeat by one prn

Or Midazolam 0.2 mg/Kg IN Repeat by one prn

Or Go to Diazepam PR Pyrexia Yes Pyrexia < 3 years: 2.5 mg PR CPG 3 to 7 years: 5 mg PR ≥ 8 years: 10 mg PR No Repeat by one prn

Check blood glucose Maximum two doses of anticonvulsant medication by Practitioner regardless of route Do not exceed adult dose Reassess

87 Clinical Practice Guidelines

SECTION 7 PAEDIATRIC EMERGENCIES

5/6.7.34 Version 3, 12/13 Septic Shock – Paediatric (≤ 15 years) P AP

Clinical signs of shock

Oxygen therapy

Request

ALS

NaCl (0.9%), 20 mL/Kg IV/IO

Meningococcal Yes Ensure appropriate PPE worn; disease suspected Mask and goggles

No Benzylpenicillin IV/IO over 3 to 5 minutes or IM < 1 year 300 mg 1 – 8 years 600 mg > 8 years 1 200 mg (1.2 g)

NaCl (0.9%), 20 mL/Kg IV/IO aliquots if signs of inadequate perfusion

ECG & SpO2 monitoring

Signs of inadequate perfusion A: (not directly affected) B: Increased respiratory rate (without increased effort) C: Tachycardia Diminished/absent peripheral pulses Delayed capillary refill D: Irritability/ confusion / ALoC E: Cool extremities, mottling

Special Authorisation: P Paramedics are authorised to continue the established infusion in the absence of an Advanced Paramedic or Doctor during transportation

88 Clinical Practice Guidelines

SECTION 7 PAEDIATRIC EMERGENCIES

4/5/6.7.35 Version 1, 12/13 Pyrexia – Paediatric (≤ 15 years) EMT P

AP Child with elevated temperature Remove/ protect from hot environment (providing it is safe to do so)

Yes Alert No

Recovery position Give cool fluids to (maintain airway) drink Check blood glucose

Cool patient

≥ 38oC temperature with Yes signs of distress or pain Paracetamol, 20 mg/Kg PO Or Paracetamol > 1 mth < 1 year: 90 mg PR 1 to 3 years: 180 mg PR No 4 to 8 years: 360 mg PR

Consider

ALS

Go to Query Septic Yes severe Shock Sepsis CPG

No

SpO2 & ECG monitor

Reference: ILCOR Guidelines 2010 RFDS, 2011, Primary Clinical Care Manual

89 Clinical Practice Guidelines

SECTION 7 PAEDIATRIC EMERGENCIES

4/5/6.7.36 Version 1, 12/13 Sickle Cell Crisis – Paediatric (≤ 15 years) EMT P

AP Sickle Cell crisis

Oxygen therapy 100% O2

Pain Go to management Yes Pain CPG required

No

Go to Elevated Pyrexia Yes temperature CPG No

If patient is cold ensure that he/she is warmed to normal temperature

Consider patient’s Encourage oral fluids care plan

Dehydration & unable to take oral No fluids

Yes

Request

ALS

NaCl (0.9%) 10 mL/Kg IV

SpO2 & ECG monitor

P Special Authorisation: Paramedics are authorised to continue the established infusion in the absence of an Advanced Paramedic or Doctor during transportation

Reference: Rees, D, 2003, GUIDELINES FOR THE MANAGEMENT OF THE ACUTE PAINFUL CRISIS IN SICKLE CELL DISEASE; British Journal of Haematology, 2003, 120, 744–752

90 Clinical Practice Guidelines

SECTION 7 PAEDIATRIC EMERGENCIES

4/5/6.7.50 Version 3, 02/14 External Haemorrhage – Paediatric (≤ 15 years) EMT P 4/5/6.7.50 Version 3, 02/14 External Haemorrhage – Paediatric (≤ 15 years) BTECEMT P Open AP BTEC woundOpen AP wound Catastrophic Active bleeding Yes Yes haemorrhage Catastrophic Active bleeding Yes Yes haemorrhage No No Posture P No No Elevation Apply tourniquet if ExaminationPosture P Elevation limb injury Request Pressure Apply tourniquet if Examination limb injury Pressure RequestALS Consider applying a dressing impregnated with haemostatic agent ALS Consider applying a dressing impregnated with haemostatic agent

Posture EMT Special Authorisation: Elevation Posture EMTs having completed the Examination EMT Special Authorisation: Elevation BTEC course may be Pressure EMTs having completed the Examination privileged by a licensed CPG BTEC course may be Pressure provider to apply a tourniquet privilegedon by its a licensedbehalf CPG provider to apply a tourniquet on its behalf

Apply sterile dressing

Apply sterile dressing

Consider Oxygen therapy Consider Oxygen therapy

Haemorrhage No controlled Haemorrhage No controlled Apply additional Yes dressing(s) Apply additional Yes dressing(s)

Haemorrhage Yes controlled Haemorrhage Yes controlled No

P No Depress proximal P pressure point Depress proximal pressure point

Haemorrhage Yes controlled Haemorrhage Yes controlled No

P No Apply tourniquet Equipment list P Apply tourniquet Sterile dressingEquipment (various sizes) list Crepe bandage (various sizes) Go to SterileConforming dressing bandage (various (various sizes) sizes) Significant Crepe bandage (various sizes) Yes Shock Triangular bandage blood loss Go to Conforming bandage (various sizes) Significant CPG Trauma tourniquet Yes Shock Triangular bandage blood loss Dressing impregnated with haemostatic agent No CPG Trauma tourniquet Dressing impregnated with haemostatic agent No

Reference: ILCOR Guidelines 2010, Reference: Granville-Chapman J, et al. Pre-hospital haemostatic dressings: A systematic review. Injury (2010), doi: 10.1016/j. injury. 2010.09.037 ILCOR Guidelines 2010, Granville-Chapman J, et al. Pre-hospital haemostatic dressings: A systematic review. Injury (2010), doi: 10.1016/j. injury. 2010.09.037 91 Clinical Practice Guidelines

SECTION 7 PAEDIATRIC EMERGENCIES

5/6.7.51 Version 3, 12/13 Shock from Blood Loss – Paediatric (≤ 15 years) P AP

Clinical signs of shock

Control external haemorrhage

Oxygen therapy

Request

ALS

Patient trapped No

Yes

NaCl (0.9%) 10 mL/Kg IV/IO

Reassess

NaCl (0.9%), 10 mL/Kg IV/IO aliquots if signs of inadequate perfusion

Continue fluid therapy until handover at ED

ECG & SpO2 monitoring

Signs of inadequate perfusion A: (not directly affected) B: Increased respiratory rate (without increased effort) C: Tachycardia Diminished/absent peripheral pulses Delayed capillary refill D: Irritability/ confusion / ALoC E: Cool extremities, mottling

P Special Authorisation: Paramedics are authorised to continue the established infusion in the absence of an Advanced Paramedic or Doctor during transportation

Reference: American Academy of Pediatrics, 2000, Pediatric Education for Prehospital Prefessionals, Jones and Bartlett.

92 Clinical Practice Guidelines

SECTION 7 PAEDIATRIC EMERGENCIES

5/6.7.52 Version 3, 12/13 Spinal Immobilisation – Paediatric (≤ 15 years) P AP

Trauma Initial indications for Use clinical spinal immobilisation judgement If in doubt, Return head to neutral position unless on immobilise movement there is Increase in Do not forcibly restrain a Pain, Resistance or Neurological symptoms patient that is combative

Remove helmet (if worn)

Dangerous mechanism include; Neck or Fall ≥ 1 metre/ 5 steps back pain or Axial load to head No midline spinal MVC > 100 km/hr, rollover or ejection tenderness ATV collision Bicycle collision Pedestrian v vehicle Yes Dangerous mechanism of injury or significant No distracting injury Are all of the factors listed present; Yes GCS = 15 Communication effective (not intoxicated with alcohol or drugs) Absence of numbness, tingling or weakness in extremities Yes Presence of low risk factors which allow safe assessment of range of motion Patient voluntarily able to rotate neck 45o left & right without pain Patient can walk without pain No

Life Immobilisation Yes No Threatening may not be indicated Apply cervical collar

Patient in Yes Go to sitting position appropriate CPG Patient in No Rapid extrication with long No undamaged Yes board/ paediatric board and child seat cervical collar Use extrication device Immobilise in child seat

Load onto vacuum mattress, paediatric board or long board

Consider Vacuum mattress

Low risk factors Simple rear end MVC Equipment list (excluding push into oncoming traffic or hit by Extrication device bus or truck) Long board Vacuum mattress Orthopaedic stretcher References; Rigid cervical collar Viccellio, P, et al, 2001, A Prospective Multicentre Study of Cervical Spine Injury in Children, Pediatrics vol 108, e20 Slack, S. & Clancy, M, 2004, Clearing the cervical spine of paediatric trauma patients, EMJ 21; 189-193

93 Clinical Practice Guidelines

SECTION 7 PAEDIATRIC EMERGENCIES

4/5/6.7.53 Version 3, 12/13 Burns – Paediatric (≤ 15 years) EMT P

Burn or AP Cease contact with heat source Scald

Inhalation and/or facial Yes Should cool for another injury 10 minutes during Airway management packaging and transfer. No Caution with hypothermia Go to Respiratory Yes Inadequate distress Ventilations CPG No

Brush off powder & irrigate Commence local Consider humidified chemical burns cooling of burn area Follow local expert direction Oxygen therapy

Remove burned clothing & jewellery (unless stuck) Equipment list Acceptable dressings Dressing/ covering Burns gel (caution for > 10% TBSA) of burn area Cling film Sterile dressing Clean sheet Go to Pain Mgt. Yes Pain > 2/10 CPG No

Isolated F: face superficial injury Caution with the very young, No H: hands (excluding FHFFP) circumferential & electrical burns F: feet F: flexion points P: perineum Yes Request TBSA burn No Yes > 5% ALS

ECG & SpO2 monitoring

> 10% TBSA and/or time from No injury to ED > 1 hour

Yes

NaCl (0.9%), IV/IO 5 to 10 years = 250 mL > 10 years = 500 mL

Monitor body temperature

Special Authorisation: Paramedics are authorised to continue P the established infusion in the absence of an Advanced Paramedic or Doctor during transportation

Reference: Allison, K et al, 2004, Consensus on the prehospital approach to burns patient management, Emerg Med J 2004; 21:112-114 Sanders, M, 2001, Paramedic Textbook 2nd Edition, Mosby 94 Clinical Practice Guidelines

SECTION 8 PRE-HOSPITAL EMERGENCY CARE OPERATIONS

4/5/6.8.1 Version 2, 01/13 Major Emergency (Major Incident) – First Practitioners on site EMT P

AP

Irish (Major Emergency) terminology in black UK (Major Incident) terminology in blue

Possible Major Emergency

Take standard infection control precautions

Consider pre-arrival information

PPE (high visibility jacket and helmet) must be worn

Practitioner 2 Practitioner 1 (Ideally MIMMS trained)

Park at the scene as safety permits and in conjunction with Fire & Carry out scene survey Garda if present Give situation report to Ambulance Control using METHANE message Leave blue lights on as vehicle acts as Forward Control Point pending the arrival of the Mobile Control Vehicle Carry out HSE Controller of Operations (Ambulance Incident Officer) role until relieved Confirm arrival at scene with Ambulance Control and provide an initial visual report stating Major Emergency (Major Incident) Liaise with Garda Controller of Operations (Police Incident Officer) Standby or Declared and Local Authority Controller of Operations (Fire Incident Officer)

Maintain communication with Practitioner 2 Select location for Holding Area (Ambulance Parking Point)

Leave the ignition keys in place and remain with vehicle Set up key areas in conjunction with other Principal Response Agencies on site; Carry out Communications Officer role until relieved - Site Control Point (Ambulance Control Point), - Casualty Clearing Station - Ambulance loading point - On site co-ordination centre

METHANE message If single Practitioner is first on site M – Major Emergency declaration / standby combine both roles until additional E – Exact location of the emergency Practitioners arrive T – Type of incident (transport, chemical etc.) H – Hazards present and potential A – Access / egress routes N – Number of casualties (injured or dead) E – Emergency services present and required

The first ambulance crew does not provide care or transport of patients as this interferes with their ability to liaise with other services, to assess the scene and to provide continuous information as the incident develops

The principles and terminology of Major Incident Medical Management and Support (MIMMS) has been used with the kind permission of the Advanced Life Support Group, UK

Reference: A Framework for Major Emergency Management, 2006, Inter-Departmental Committee on Major Emergencies (Replaced by National Steering Group on Major Emergency Management) 95 Clinical Practice Guidelines

SECTION 8 PRE-HOSPITAL EMERGENCY CARE OPERATIONS

4/5/6.8.2 Version 2, 01/13 Major Emergency (Major Incident) – Operational Control EMT P

AP Irish (Major Emergency) terminology in black UK (Major Incident) terminology in blue If Danger Area identified, entry to Danger Area is controlled by a Senior Traffic Cordon Fire Officer or an Garda Síochána

Outer Cordon

Inner Cordon

Danger Area

Body Casualty Site Control Holding Clearing Point Area Station HSE Garda LA Holding Holding Holding Ambulance Area Area Area Loading Point

Entry to Outer Cordon (Silver area) One way ambulance circuit Entry to Inner Cordon (Bronze Area) is is controlled by an Garda Síochána limited to personnel providing emergency care and or rescue Personal Protective Equipment required

Management structure for; Management structure for; Outer Cordon, Tactical Area (Silver Area) Inner Cordon, Operational Area (Bronze Area) On-Site Co-ordinator Forward Ambulance Incident Officer (Forward Ambulance Incident Officer) HSE Controller of Operations (Ambulance Incident Officer) Forward Medical Incident Officer (Forward Medical Incident Officer) Site Medical Officer (Medical Incident Officer) Fire Service Incident Commander (Forward Fire Incident Officer) Local Authority Controller of Operations (Fire Incident Officer) Garda Cordon Control Officer (Forward Police Incident Officer) Garda Controller of Operations (Police Incident Officer)

Other management functions for; Major Emergency site Please note that Controller of Casualty Clearing Officer Operations may be other than Triage Officer ambulance or fire officers, depending Ambulance Parking Point Officer on the nature of the emergency Ambulance Loading Point Officer Communications Officer Safety Officer

LOCAL AUTHORITY HSE GARDA CONTROLLER CONTROLLER CONTROLLER

Reference: A Framework for Major Emergency Management, 2006, Inter-Departmental Committee on Major Emergencies (Replaced by National Steering Group on Major Emergency Management)

The principles and terminology of Major Incident Medical Management and Support (MIMMS) has been used with the kind permission of the Advanced Life Support Group, UK 96 Clinical Practice Guidelines

SECTION 8 PRE-HOSPITAL EMERGENCY CARE OPERATIONS

4/5/6.8.3 Version 1, 05/08 Triage Sieve EMT P

AP Multiple casualty incident

Priority 3 Can casualty (Delayed) Yes walk GREEN No

Is casualty Yes No breathing

Open airway one attempt

Breathing now No DEAD

Yes

Respiratory rate Yes < 10 or > 29 Priority 1 No (Immediate)

RED Capillary refill > 2 sec Or Yes Pulse > 120

No Priority 2 (Urgent)

YELLOW

Triage is a dynamic process

The principles and terminology of Major Incident Medical Management and Support (MIMMS) has been used with the kind permission of the Advanced Life Support Group, UK

97 Clinical Practice Guidelines

SECTION 8 PRE-HOSPITAL EMERGENCY CARE OPERATIONS

5/6.8.4 Version 1, 05/08 Triage Sort P AP

Multiple casualty incident

Triage is a dynamic Cardiopulmonary function Measured value Score Insert score process 10 – 29 / min 4 > 29 / min 3 Respiratory Rate 6 – 9 / min 2 A 1 – 5 / min 1 None 0 ≥ 90 mm Hg 4 76 – 89 mm Hg 3 Systolic Blood 50 – 75 mm Hg 2 B Pressure 1 – 49 mm Hg 1 No BP 0 13 – 15 4 9 – 12 3 Glasgow Coma Scale 6 – 8 2 C 4 – 5 1 3 0 Triage Revised Trauma Score A+B+C Priority 1 (Immediate) 1 - 10 RED

Priority 2 (Urgent) 11 YELLOW Revised Trauma Score Priority 3 12 (Delayed) GREEN

Spontaneous 4 To Voice 3 Eye Opening 0 DEAD To Pain 2 None 1

Oriented 5 Confused 4 Verbal Inappropriate words 3 Response Incomprehensible sounds 2 None 1 Obeys commands 6 Localises pain 5 Motor Withdraw (pain) 4 Response Flexion (pain) 3 Extension (pain) 2 None 1 Glasgow Coma Scale

The principles and terminology of Major Incident Medical Management and Support (MIMMS) has been used with the kind permission of the Advanced Life Support Group, UK 98 Clinical Practice Guidelines

SECTION 8 PRE-HOSPITAL EMERGENCY CARE OPERATIONS

5/6.8.5 Version 1, 05/08 Conducted Electrical Weapon (Taser) P AP 5/6.8.5 Version 1, 05/08 Conducted Electrical Weapon (Taser) P AP Prior to touching the patient ensure Taser that the Garda has disconnected gun used Prior to touching the patient ensure Taser the wires from the hand held unit that the Garda has disconnected gun used the wires from the hand held unit Go to Complete appropriate primary survey GoCPG to Complete appropriate primary survey CPG Cut wire connection proximal to barbs Cut wire connection proximal to barbs

Monitor ECG & SpO2 for minimum 15 minutes Monitor ECG & SpO2 for minimum 15 minutes Go to Behavioural Yes Behavioural emergency emergencyGo to Behavioural Yes BehaviouralCPG emergencyNo emergency CPG No Patient care takes precedent Remove barbs Barbs should not be removed if over removal of barb Clean and dress wounds they are embedded in the face, Remove barbs Patient care takes precedent eye,Barbs neck, should or groinnot be removed if over removal of barb Clean and dress wounds they are embedded in the face, eye, neck, or groin Monitor GCS, temperature & vital signs Monitor GCS, temperature & vital signs

Monitor for signs of Excited Delirium Monitor for signs of Excited Delirium

Consider Oxygen therapy Consider Oxygen therapy

Ensure Garda accompany patient at all times Ensure Garda accompanies patient at all times

Note: This CPG was developed in conjunction with theNote: Chief Medical Officer, An Garda Síochána This CPG was developed in conjunction with the Chief Medical Officer, An Garda Síochána

Reference: DSAC Sub-committee on the Medical Implications of Less-lethal Weapons 2004, Second statement on the medical implications of the use of the M26 AdvancedReference: Taser. UnitedDSAC Sub-committeeStates Government on the Accountability Medical Implications Office, 2005, of Less-lethal The use ofWeapons Taser by 2004, selected Second law enforcementstatement on agencies the medical implications of the use of the M26 ManitobaAdvanced health Taser. Emergency Medical Services, 2007 Taser Dart Removal Protocol United States Government Accountability Office, 2005, The use of Taser by selected law enforcement agencies Manitoba Health Emergency Medical Services, 2007 Taser Dart Removal Protocol 99 Clinical Practice Guidelines

SECTION 9 TREAT & REFERRAL

5/6.9.1 Version 2, 01/13 Clinical Care Pathway Decision – Treat & Referral P AP

From Non serious or relevant CPGs non life threat

Administer specific treatment Patient responds to No & provide patient with the Generic patient inclusion intervention(s) opportunity to recover/ 1. ≥ 18 years & ≤ 60 years. respond 2. Not pregnant. Yes 3. Social support available. 4. Demonstrates capacity and willing to engage. Conduct complete patient assessment 5. Reliable history. Focused history 6. Vital signs within normal range (following care). Systematic physical examination 7. Compliant with treatment, including own medications. 8. Clinical status of ‘Non serious or non life threat All generic (following care). inclusion criteria No 9. Absence of self-inflicted injury or assault. present 10. No observed significant relevant co-morbidity. 11. 1st call for same condition within 30 days. Yes 12. Registered with general practitioner. If in any doubt about generic inclusions the practitioner should transport to ED Practitioner satisfied with non No ED care

Yes

CPG If medical practitioner is present; for treat & referral follow direction on transport No available for decision condition Transport to ED

Yes

An adult carer, both capable & No willing to accept responsibility, available Yes

Explain clinical pathway options to Vital sign Normal range patient and carer Respiratory Rate 12 – 20

SpO2 ≥ 96%

Inspired O2 Room air Patient & Systolic BP 111 - 150 No carer accepts non Pulse (BPM) 51 - 90 ED care AVPU/CNS Response Alert Yes Temperature (oC) 36 – 37.5

Go to Clinical Care Pathway options appropriate CP1 Treat & Transport to an Emergency Department T&R CPG CP2 Treat & Referral for follow-up care within 2 hours (arranged with local practitioner) CP3 Treat & Referral for follow-up care within 48 hours or as soon as practicable CP4 Treat & Referral to self-care with after-care instructions

Reference: Ambulance Service of NSW, 2008, CARE Clinical Pathways HSE Acute Medicine Programme, 2011, Guiding Framework and Policy for the National Early Warning Score System to Recognise and Respond to Clinical Deterioration 100 Clinical Practice Guidelines

SECTION 9 TREAT & REFERRAL

5/6.9.2 Version 2, 01/13 Hypoglycaemia – Treat & Referral P AP 5/6.9.2 Version 2, 01/13 Hypoglycaemia – Treat & Referral P AP From Clinical Previously PathwayFrom diagnosed with Specific Hypoglycaemic exclusion DecisionClinical Previouslydiabetes 1. First ever hypoglycaemic episode. PathwayCPG diagnosed with 2.Specific < 30 days Hypoglycaemic since last episode. exclusion Decision diabetes 3.1. Unable First ever or hypoglycaemicunwilling to eat. episode. CPG 4.2. Latest< 30 days blood since glucose last episode. < 4.0 mmol/L (after treatment). 5.3. Unable No serial or improvement unwilling to eat. of blood glucose. Exclusions 4. Latest blood glucose < 4.0sulphonylurea mmol/L (after tablets treatment). in Yes 6. On oral hypoglycaemics ( present 5. particular) No serial improvement. of blood glucose. Exclusions sulphonylurea tablets in Yes 7.6. RecentOn oral medicationhypoglycaemics change ( or additional presentNo particular)medications. prescribed (within 30 days). 8.7. RecentSeizure medicationin association change with hypoglycaemiaor additional No 9. Imedicationsnsulin or oral prescr hypoglycaemicsibed (within overdose30 days). If8. inSeizure any doubt in association about 1 withto 9 abovehypoglycaemia the practitioner should9. Insulin transport or oral hypoglycaemics to ED overdose If in any doubt about 1 to 9 above the practitioner should transport to ED

CP 1 CP 2 CP 3 CP 4

CP 1 CP 2 CP 3 CP 4 Transport Immediate 48 hours Self-care

Transport Immediate 48 hours Self-care

1. Complete after-care Instructions and give a copy to the patient or carer 2. Complete the PCR and mark for Clinical Audit 1. Complete after-care Instructions and give a copy to the patient or carer 2. Complete the PCR and mark for Clinical Audit

Ensure patient takes in both quick (lucozade, fruit juice or sweets) and longerEnsure-acting patient (bread, takes intoast, both biscuit) quick carbohydrates(lucozade, fruit juice or sweets) and longer-acting (bread, toast, biscuit) carbohydrates If the patient expresses a Flush line with 10 mL NaCl following removal wish to attend an Emergency If the patient expresses a Flushof 10% line Dextrose with 10 mL Department then NaClinfusion following removal arrangementswish to attend shallan Emergency be made of 10% Dextrose toDepartment transport thenhim/her there infusion arrangements shall be made to transport him/her there

Reference: HSE Diabetes Programme, 2012. Ambulance Service of NSW, 2008, CARE Clinical Pathways Reference: O’Donnell HSE Diabetes C, 2007, Programme, Hypoglycaemia 2012. Treat and Discharge Protocol (unpublished) AmbulanceCarter A, et al Service 2002, Transport of NSW, Refusal 2008, by CARE Hypoglycaemic Clinical Pathways Patients after On-scene Intravenous Dextrose, Academic Emergency medicine, Vol. 9, No. 8:p855-857 O’Donnell C, 2007, Hypoglycaemia Treat and Discharge Protocol (unpublished) Carter A, et al 2002, Transport Refusal by Hypoglycaemic Patients after On-scene Intravenous Dextrose, Academic Emergency medicine, Vol. 9, No. 8:p855-857 101 Clinical Practice Guidelines

SECTION 9 TREAT & REFERRAL 5/6.9.3 Version 2, 01/13 Isolated seizure – Treat & Referral P AP 5/6.9.3 Version 2, 01/13 Isolated seizure – Treat & Referral P AP From Clinical Specific seizure exclusion Pathway Known epileptic 1. First seizure. From 2. Anticonvulsant administered. Decision Specific seizure exclusion Clinical 3. Concurrent acute illness (including abnormal CPG 1. First seizure. Pathway Known epileptic temperature). 2. Anticonvulsant administered. Decision 4. History of multi seizure presentations. CPG 3. Concurrent acute illness (including abnormal 5. History of recent head injury. temperature). 6. Increased frequency of seizures. Exclusions 4. History of multi seizure presentations. Yes 7. Seizure involving submersion or injury. present 5. History of recent head injury. 8. Seizure type or pattern differing to usual presentation. 6. Increased frequency of seizures. Exclusions 9. Suspicion of overdose / ingestion / aspiration. Yes No 7. Seizure involving submersion or injury. present 10. Unwitnessed seizure. 8. Seizure type or pattern differing to usual presentation. 11. Two or more seizures within 24 hours. 9. Suspicion of overdose / ingestion / aspiration. No 12. Glucose < 4 mmol/L. 10. Unwitnessed seizure. 13. Recent medication change or additional medications 11. Two or more seizures within 24 hours. prescribed (within 30 days). 12. Glucose < 4 mmol/L. If in any doubt about 1 to 13 above the practitioner 13. Recent medication change or additional medications should transport to ED prescribed (within 30 days). If in any doubt about 1 to 13 above the practitioner should transport to ED

CP 1 CP 2 CP 3 CP 4

TransportCP 1 ImmediateCP 2 48CP hours 3 SelfCP-care 4

Transport Immediate 48 hours Self-care

1. Complete after-care Instructions and give a copy to the patient or carer 2. Complete the PCR and mark for Clinical Audit

1. Complete after-care Instructions and give a copy to the patient or carer 2. Complete the PCR and mark for Clinical Audit

Isolated seizure: Lasting < 5 minutes Similar to previous events Isolated seizure: Lasting < 5 minutes Similar to previous events

If the patient expresses a wish to attend an Emergency Department then If the patient expresses a arrangements shall be made wish to attend an Emergency to transport him/her there Department then arrangements shall be made to transport him/her there

Reference: HSE Epilepsy Programme 2012 Ambulance Service of NSW, 2008, CARE Clinical Pathways NICHOLL, J. S. 1999. Prehospital management of the seizure patient. Emerg Med Serv, 28, 71-5. Simonson, H and Pelberg, A, 1993, Unnecessary Emergency Transport and Care of Grand Mal Seizures, American Journal of Medical Quality, Vol 8, No 2, p53-55. Reference : Mechem,HSE Epilepsy CC et Programme al, 2001, Short-term 2012 outcome of seizure patients who refuse transport after out-of-hospital evaluation, Academy of Emergency Medicine, Mar;8(3):231-6 Ambulance Service of NSW, 2008, CARE Clinical Pathways NICHOLL, J. S. 1999. Prehospital management of the seizure patient. Emerg Med Serv, 28, 71-5. Simonson, H and Pelberg, A, 1993, Unnecessary Emergency Transport and Care of Grand Mal Seizures, American Journal of Medical Quality, Vol 8, No 2, p53-55. Mechem, CC et al, 2001, Short-term outcome of seizure patients who refuse transport after out-of-hospital evaluation, Academy of Emergency Medicine, Mar;8(3):231-6 102 Clinical Practice Guidelines

APPENDIX 1 MEDICATION FORMULARY

The Medication Formulary is published by the Pre-Hospital Emergency Care Council (PHECC) to enable pre-hospital emergency care practitioners to be competent in the use of medications permitted under the Medicinal Products 7th Schedule (SI 300 of 2014). This is a summary document only and practitioners are advised to consult with official publications to obtain detailed information about the medications used.

The Medication Formulary is recommended by the Medical Advisory Committee (MAC) prior to publication by Council.

The medications herein may be administered provided:

1 The practitioner is in good standing on the PHECC practitioner’s Register. 2 The practitioner complies with the Clinical Practice Guidelines (CPGs) published by PHECC. 3 The practitioner is acting on behalf of an organisation (paid or voluntary) that is a PHECC licensed CPG provider. 4 The practitioner is privileged, by the organisation on whose behalf he/she is acting, to administer the medications. 5 The practitioner has received training on, and is competent in, the administration of the medication. 6 The medications are listed on the Medicinal Products 7th Schedule.

The context for administration of the medications listed here is outlined in the CPGs.

Every effort has been made to ensure accuracy of the medication doses herein. The dose specified on the relevant CPG shall be the definitive dose in relation to practitioner administration of medications. The principle of titrating the dose to the desired effect shall be applied. The onus rests on the practitioner to ensure that he/she is using the latest versions of CPGs which are available on the PHECC website www.phecc.ie

Sodium Chloride 0.9% (NaCl) is the IV/IO fluid of choice for pre-hospital emergency care.

Water for injection shall be used when diluting medications, however if not available NaCl (0.9%) may be used if not contraindicated.

All medication doses for patients ≤ 15 years shall be calculated on a weight basis unless an age-related dose is specified for that medication.

The route of admistration should be appropriate to the patients clinical presentation.

The dose for paediatric patients may never exceed the adult dose.

Paediatric weight estimations acceptable to PHECC are:

Neonate 3.5 Kg

Six months 6 Kg

One to five years (age x 2) + 8 Kg

Greater than 5 years (age x 3) + 7 Kg

Reviewed on behalf of PHECC by Prof Peter Weedle, Adjunct Professor of Clinical Pharmacy, School of Pharmacy, University College Cork.

This version contains 17 medications.

103 Clinical Practice Guidelines

APPENDIX 1 MEDICATION FORMULARY

Amendments to the 2012 Edition

The paediatric age range has been increased to reflect the HSE National Clinical Programme for Paediatrics and Neonatology age profile:

A paediatric patient is defined as a patient up to the eve of his/her 16th birthday (≤ 15 years).

Water for injection shall be used when diluting medications, however if not available NaCl (0.9%) may be used if not contraindicated.

The paediatric weight estimation formulae have been modified.

New Medications introduced;

• Hydrocortisone • Ticagrelor

Clopidogrel HEADING ADD DELETE

Indications ST Elevation Myocardial Infarction (STEMI) if the patient is Identification of ST Elevation not suitable for PPCI Myocardial Infarction (STEMI)

Usual Dosages 300 mg PO 600 mg PO ≥ 75 years > 75 years

Additional information Paramedics are authorised to administer Clopidogrel PO following identification of STEMI and medical practitioner instruction

Epinephrine (1:1,000) HEADING ADD DELETE

Usual Dosages Auto-injector EpiPen® Jr

104 Clinical Practice Guidelines

APPENDIX 1 MEDICATION FORMULARY

Ibuprofen HEADING ADD DELETE

Clinical Level

Presentation 400 mg tablet

Description It is an anti-inflammatory analgesic It is used to reduce mild to moderate pain

Additional information Caution with significant burns or poor perfusion due to risk of kidney failure Caution if concurrent NSAIDs use

Ipratropium Bromide HEADING ADD DELETE

Clinical Level

Administration CPG: 4/5/6.3.3, 4/5/6.3.4, 4/5/6.7.18 CPG: 5/6.3.2, 5/6.7.5

Usual Dosages Paediatric Paediatric < 12 years: 0.25 mg NEB 0.25 mg NEB ≥ 12 years: 0.5 mg NEB

105 Clinical Practice Guidelines

APPENDIX 1 MEDICATION FORMULARY

Midazolam Solution HEADING ADD DELETE

Administration 2.5 mg in 0.5 mL pre-filled syringe 5 mg in 1 mL pre-filled syringe 7.5 mg in 1.5 mL pre-filled syringe 10 mg in 2 mL pre-filled syringe

Indications Combative with hallucinations or paranoia and risk to self Psychostimulant overdose or others Hallucinations or paranoia

Usual Dosages Seizure: Paediatric: < 1 year: 2.5 mg buccal Seizure: 0.5 mg/Kg buccal 1 year to < 5 years: 5 mg buccal Psychostimulant overdose: 2.5 mg IV or 5 mg IM (Repeat x 2 5 years to < 10 years: 7.5 mg buccal prn) ≥ 10 years: 10 mg buccal Hallucinations or paranoia: 5 mg IV/IM

Additional information No more than two doses by practitioners. Practitioners should The maximum dose of take into account the dose administered by caregivers prior Midazolam includes that to arrival of practitioner. administered by caregiver prior to arrival of Practitioner

Naloxone HEADING ADD DELETE

Clinical level

Administration Intranasal (IN). CPG: 5/6.3.2, 5/6.7.5 CPG: 6.4.23, 4/5.4.23, 4/5/6.7.5

Indications Inadequate respiration and/or ALoC following known or Respiratory rate < 10 secondary suspected narcotic overdose to known or suspected narcotic overdose

Usual Dosages Adult: 0.8 mg (800 mcg) IN (EMT) (Paramedic repeats by one prn) Paediatric: 0.02 mg/Kg (20 mcg/Kg) IN (EMT)

Nitrous Oxide 50% and Oxygen 50% (Entonox®) HEADING ADD DELETE

Additional information Caution when using Entonox for greater than one hour for Sickle Cell Crisis

106 Clinical Practice Guidelines

APPENDIX 1 MEDICATION FORMULARY

Oxygen HEADING ADD DELETE

Contraindications Paraquat poisoning

Indications Sickle Cell Disease - 100%

Additional Information Caution with paraquat poisoning, administer oxygen if SpO2 < 92%

Paracetamol HEADING ADD DELETE

Presentation 250 mg in 5 mL

Indications Pyrexia Pyrexia following seizure for paediatric patients. Advanced Paramedics may administer Paracetamol, in the absence of a seizure for the current episode, provided the paediatric patient is pyrexial and has a previous history of febrile convulsions.

Contraindications < 1 month old

Usual Dosages > 1 month < 1 year - 90 mg PR < 1 year - 60 mg PR

Salbutamol HEADING ADD DELETE

Administration Advanced Paramedics may repeat Salbutamol x 3

Usual Dosages Adult: Adult: .. (or 0.1 mg metered aerosol spray x 5) Repeat at 5 min prn (APs x 3 Repeat at 5 min prn and Ps x 1) (EFRs: 0.1 mg metered aerosol spray x 2) (EMTs & EFRs: 0.1 mg metered aerosol spray x 2)

Paediatric: Paediatric: < 5 yrs…(or 0.1 mg metered aerosol spray x 3) Repeat at 5 min prn (APs x 3 and Ps x 1) ≥ 5 yrs…(or 0.1 mg metered aerosol spray x 5) (EMTs & EFRs: 0.1 mg metered Repeat at 5 min prn aerosol spray x 2) (EFRs: 0.1 mg metered aerosol spray x 2)

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Sodium Chloride 0.9% HEADING ADD DELETE

Usual Dosages Adult: Adult: Suspension Trauma, PEA or Asystole: 20 mL/Kg IV/IO Post-resuscitation care: 500 mL infusion IV/IO infusion Adrenal insufficiency: 1,000 mL IV/IO infusion Heat-Related Emergency: 1,000 mL IV/IO infusion Shock; 500 mL IV/IO infusion Hypothermia, Sepsis, # neck of femur and Bradycardia: Repeat in aliquots of 250 mL …Repeat to max 1 L prn to maintain systolic BP of; Post-resuscitation care: 1,000 mL IV/IO infusion 100 mmHg (hypovolaemia or Shock from blood loss; … to maintain systolic BP of septic). 90 – 100 mmHg Sickle Cell Crisis: 1,000 mL IV/IO infusion 90 – 100 mmHg (head injury # neck of femur, sepsis: 250 mL IV infusion GCS > 8) Sepsis with poor perfusion: 500 mL IV/IO infusion Post partum haemorrhage; 1,000 mL IV/IO infusion Paediatric: Glycaemic emergency: 20 mL/ Paediatric: Kg IV/IO infusion Glycaemic emergency: 10 mL/Kg IV/IO infusion Hypothermia: 10 mL/Kg IV/IO infusion ... Repeat prn x 1 Hypothermia: 20 mL/Kg IV/IO Adrenal insufficiency, Septic shock, Symptomatic infusion Bradycardia, Asystole/PEA: 20 mL/Kg IV/IO infusion Burns: …. > 1 hour ….. Shock: 20 mL/Kg IV/IO infusion

Please visit www.phecc.ie for the latest edition/version.

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APPENDIX 1 MEDICATION FORMULARY CLINICAL LEVEL: LIST OF MEDICATIONS

Aspirin ...... 110 Clopidogrel ...... 111 Epinephrine 1mg/1ml (1:1000) ...... 112 Glucagon ...... 113 Glucose gel ...... 114 Glyceryl Trinitrate (GTN) ...... 115 Hydrocortisone ...... 116 Ibuprofen ...... 117 Ipratropium Bromide ...... 118 Midazolam Solution ...... 119 Naloxone ...... 121 Nitrous Oxide 50% and Oxygen 50% (Entonox®) ...... 122 Oxygen ...... 123 Paracetamol ...... 124 Salbutamol ...... 125 Sodium Chloride 0.9% (NaCl) ...... 126 Ticagrelor ...... 128

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Medication Aspirin

Class Platelet aggregation inhibitor

Descriptions Anti-inflammatory agent and an inhibitor of platelet function Useful agent in the treatment of various thromboembolic diseases such as acute myocardial infarction

Presentation 300 mg dispersible tablet

Administration Orally (PO) - dispersed in water, or to be chewed - if not dispersible form (CPG: 5/6.4.10, 4.4.10, 1/2/3.4.10)

Indications Cardiac chest pain or suspected Myocardial Infarction

Contraindications Active symptomatic gastrointestinal (GI) ulcer Bleeding disorder (e.g. haemophilia) Known severe adverse reaction Patients < 16 years old

Usual Dosages Adult: 300 mg tablet

Paediatric: Contraindicated

Pharmacology/Action Antithrombotic Inhibits the formation of thromboxane A2, which stimulates platelet aggregation and artery constriction. This reduces clot/thrombus formation in an MI.

Side effects Epigastric pain and discomfort Bronchospasm Gastrointestinal haemorrhage

Long-term effects Generally mild and infrequent but incidence of gastro-intestinal irritation with slight asymptomatic blood loss, increased bleeding time, bronchospasm and skin reaction in hypersensitive patients.

Additional information Aspirin 300 mg is indicated for cardiac chest pain regardless if patient is on anticoagulants or is already on Aspirin.

If the patient has swallowed an aspirin (enteric coated) preparation without chewing it, the patient should be regarded as not having taken any aspirin; administer 300 mg PO.

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Medication Clopidogrel

Class Platelet aggregation inhibitor

Description An inhibitor of platelet function

Presentation 300 mg tablet 75 mg tablet

Administration Orally (PO) (CPG: 5/6.4.10)

Indications ST Elevation Myocardial Infarction (STEMI) if the patient is not suitable for PPCI

Contraindications Known severe adverse reaction Active pathological bleeding Severe liver impairment

Usual Dosages Adult: 300 mg PO ≥ 75 years; 75 mg PO

Paediatric: Not indicated

Pharmacology/Action Clopidogrel selectively inhibits the binding of adenosine diphosphate (ADP) to its platelet receptor, and the subsequent ADP-mediated activation of the GPIIb/IIIa complex, thereby inhibiting platelet aggregation. Biotransformation of Clopidogrel is necessary to produce inhibition of platelet aggregation. Clopidogrel acts by irreversibly modifying the platelet ADP receptor.

Side effects Abdominal pain Dyspepsia Diarrhoea

Additional information If a patient has been loaded with an anti-platelet medication (other than Aspirin), prior to the arrival of the practitioner, the patient should not have Clopidogrel administered.

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Medication Epinephrine (1:1,000)

Class Sympathetic agonist

Description Naturally occurring catecholamine. It is a potent alpha and beta adrenergic stimulant; however, its effect on beta receptors is more profound.

Presentation Pre-filled syringe, ampoule or Auto injector (for EMT use) 1 mg/1 mL (1:1,000)

Administration Intramuscular (IM) (CPG: 5/6.4.15, 4.4.15, 2/3.4.16, 5/6.7.31, 4.7.31, 2/3.7.31)

Indications Severe anaphylaxis

Contraindications None known

Usual Dosages Adult: 0.5 mg (500 mcg) IM (0.5 mL of 1: 1,000) EMT 0.3 mg (Auto injector) Repeat every 5 minutes if indicated

Paediatric: < 6 months: 0.05 mg (50 mcg) IM (0.05 mL of 1:1 000) 6 months to 5 years: 0.125 mg (125 mcg) IM (0.13 mL of 1:1 000) 6 to 8 years: 0.25 mg (250 mcg) IM (0.25 mL of 1:1 000) > 8 years: 0.5 mg (500 mcg) IM (0.5 mL of 1:1 000) EMT: 6 months < 10 years; 0.15 mg (Auto injector) ≥ 10 years; 0.3 mg (Auto injector) Repeat every 5 minutes if indicated

Pharmacology/Action Alpha and beta adrenergic stimulant Reversal of laryngeal oedema & bronchospasm in anaphylaxis Antagonises the effects of histamine

Side effects Palpitations Tachyarrhythmias Hypertension Angina-like symptoms

Additional information N.B. Double check the concentration on pack before use

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Medication Glucagon

Class Hormone and Antihypoglycaemic

Description Glucagon is a protein secreted by the alpha cells of the Islets of Langerhans in the pancreas. It is used to increase the blood glucose level in cases of hypoglycaemia in which an IV cannot be immediately placed.

Presentation 1 mg vial powder and solution for reconstitution (1 mL)

Administration Intramuscular (IM) (CPG: 5/6.4.19, 4.4.19, 5/6.7.32, 4.7.32)

Indications Hypoglycaemia in patients unable to take oral glucose or unable to gain IV access, with a blood glucose level < 4 mmol/L.

Contraindications Known severe adverse reaction Phaeochromocytoma

Usual Dosages Adult: 1 mg IM

Paediatric: ≤ 8 years 0.5 mg (500 mcg) IM > 8 years 1 mg IM

Pharmacology/Action Glycogenolysis Increases plasma glucose by mobilising glycogen stored in the liver

Side effects Rare, may cause hypotension, dizziness, headache, nausea & vomiting.

Additional information May be ineffective in patients with low stored glycogen e.g. prior use in previous 24 hours, alcoholic patients with liver disease.

Store in refrigerator Protect from light

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Medication Glucose gel

Class Antihypoglycaemic

Description Synthetic glucose paste

Presentation Glucose gel in a tube or sachet

Administration Buccal administration: Administer gel to the inside of the patient’s cheek and gently massage the outside of the cheek. (CPG: 5/6.4.19, 4.4.19, 2/3.4.19, 5/6.7.32, 4.7.32)

Indications Hypoglycaemia Blood glucose < 4 mmol/L EFR – Known diabetic with confusion or altered levels of consciousness

Contraindications Known severe adverse reaction

Usual Dosages Adult: 10 – 20 g buccal Repeat prn

Paediatric: ≤ 8 years; 5 – 10 g buccal > 8 years: 10 – 20 g buccal Repeat prn

Pharmacology/Action Increases blood glucose levels

Side effects May cause vomiting in patients under the age of five if administered too quickly

Additional information Glucose gel will maintain glucose levels once raised but should be used secondary to Dextrose to reverse hypoglycaemia.

Proceed with caution: Patients with airway compromise Altered level of consciousness

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Medication Glyceryl Trinitrate (GTN)

Class Nitrate

Description Special preparation of Glyceryl trinitrate in an aerosol form that delivers precisely 0.4 mg of Glyceryl trinitrate per spray.

Presentation Aerosol spray: metered dose 0.4 mg (400 mcg)

Administration Sublingual (SL): Hold the pump spray vertically with the valve head uppermost Place as close to the mouth as possible and spray under the tongue The mouth should be closed after each dose (CPG: 5/6.3.5, 4.4.10, 5/6.4.10)

Indications Angina Suspected Myocardial Infarction (MI) EFRs may assist with administration Advanced Paramedic and Paramedic - Pulmonary oedema

Contraindications SBP < 90 mmHg Viagra or other phosphodiesterase type 5 inhibitors (Sildenafil, Tadalafil and Vardenafil) used within previous 24 hours. Known severe adverse reaction

Usual Dosages Adult: Angina or MI: 0.4 mg (400 mcg) Sublingual Repeat at 3-5 min intervals, Max: 1.2 mg EFRs 0.4 mg sublingual max Pulmonary oedema; 0.8 mg (800 mcg) sublingual Repeat x 1

Paediatric: Not indicated

Pharmacology/Action Vasodilator Releases nitric oxide which acts as a vasodilator. Dilates coronary arteries particularly if in spasm increasing blood flow to myocardium. Dilates systemic veins reducing venous return to the heart (pre load) and thus reduces the heart’s workload. Reduces BP.

Side effects Headache Transient Hypotension Flushing Dizziness

Additional information If the pump is new or has not been used for a week or more, the first spray should be released into the air.

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Medication Hydrocortisone

Class Corticosteroid and anti-inflammatory

Description Hydrocortisone is a potent corticosteroid with anti-inflammatory properties

Presentation Powder and solvent for solution for injection or infusion. Vial containing off-white powder and vial containing water for injections. Prepare the solution aseptically by adding not more than 2 mL of Sterile Water for Injections to the contents of one 100 mg vial, shake and withdraw for use.

Administration Intravenous (IV) infusion Intramuscular (IM) The preferred route for initial emergency use is intravenous (CPG: 4/5/6.3.3, 4/5/6.3.4, 5/6.4.13, 5/6.4.15, 4/5/6.7.12, 5/6.7.30, 5/6.7.31)

Indications Severe or recurrent anaphylactic reactions Asthma refractory to Salbutamol and Ipratropium Bromide Exacerbation of COPD (Advanced Paramedic) Adrenal insufficiency (Paramedic)

Contraindications No major contraindications in acute management of anaphylaxis

Usual Dosages Adult: Anaphylactic reaction and Exacerbation of COPD (AP): 200 mg IV (infusion in 100 mL NaCl) or IM Asthma (AP) and Adrenal insufficiency (P & AP): 100 mg IV (infusion in 100 mL NaCl) or IM

Paediatric: Anaphylactic reaction and Asthma (AP); < 1 year 25 mg IV (infusion in 100 mL NaCl) or IM 1 to 5 years 50 mg IV (infusion in 100 mL NaCl) or IM > 5 years 100 mg IV (infusion in 100 mL NaCl) or IM Adrenal insufficiency (P & AP); 6 mths to ≤ 5 years: 50 mg IV (infusion in 100 mL NaCl) or IM > 5 years : 100 mg IV (infusion in 100 mL NaCl) or IM

Pharmacology/Action Potent anti-inflammatory properties and inhibits many substances that cause inflammation

Side effects CCF, hypertension, abdominal distension, vertigo, headache, nausea, malaise and hiccups

Long-term side effects Adrenal cortical atrophy develops during prolonged therapy and may persist for months after stopping treatment

Additional information Intramuscular injection should avoid the deltoid area because of the possibility of tissue atrophy. Dosage should not be less than 25 mg.

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Medication Ibuprofen

Class Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

Description It is an anti-inflammatory analgesic

Presentation Suspension 100 mg in 5 mL 200 mg tablet, 400 mg tablet

Administration Orally (PO) (CPG: 4/5/6.2.6, 4/5/6.7.5)

Indications Mild to moderate pain

Contraindications Not suitable for children under 3 months Patient with history of asthma exacerbated by aspirin Pregnancy Peptic ulcer disease Known severe adverse reaction

Usual Dosages Adult: 400 mg PO

Paediatric: 10 mg/Kg PO

Pharmacology/Action Suppresses prostaglandins, which cause pain via the inhibition of cyclooxygenase (COX). Prostaglandins are released by cell damage and inflammation.

Side effects Skin rashes, gastrointestinal intolerance and bleeding

Long-term side effects Occasionally gastrointestinal bleeding and ulceration occurs. May also cause acute renal failure, interstitial nephritis and NSAID-associated nephropathy.

Additional information If Ibuprofen administered in previous 6 hours, adjust the dose downward by the amount given by other sources resulting in a maximum of 10 mg/Kg. Caution with significant burns or poor perfusion due to risk of kidney failure. Caution if concurrent NSAIDs use.

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Medication Ipratropium Bromide

Class Anticholinergic

Description It is a parasympatholytic bronchodilator that is chemically related to atropine.

Presentation Nebuliser Solution 0.25 mg (250 micrograms) in 1 mL

Administration Nebulised (NEB) mixed with age-specific dose of Salbutamol (CPG: 4/5/6.3.3, 4/5/6.3.4, 4/5/6.7.12)

Indications Acute severe asthma or exacerbation of COPD not responding to initial Salbutamol dose.

Contraindications Known severe adverse reaction

Usual Dosages Adult: 0.5 mg NEB

Paediatric: < 12 years: 0.25 mg NEB ≥ 12 years: 0.5 mg NEB

Pharmacology/Action It blocks muscarinic receptors associated with parasympathetic stimulation of the bronchial air passageways. This results in bronchial dilation and reduced bronchial secretions.

Side effects Transient dry mouth, blurred vision, tachycardia and headache.

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Medication Midazolam Solution

Class Benzodiazepine

Description It is a potent sedative agent. Clinical experience has shown Midazolam to be 3 to 4 times more potent per mg as Diazepam.

Presentation Ampoule 10 mg in 2 mL or ampoule 10 mg in 5 mL. Buccal liquid 50 mg in 5 mL. Pre-filled syringe 2.5 mg in 0.5 mL. Pre-filled syringe 5 mg in 1 mL. Pre-filled syringe 7.5 mg in 1.5 mL. Pre-filled syringe 10 mg in 2 mL. Pre-filled syringe 10 mg in 1 mL.

Administration Intravenous (IV). Intraosseous (IO). Intramuscular (IM). Buccal. Intranasal (IN) (50% in each nostril). (CPG: 5/6.4.23, 6.4.29, 5/6.7.33).

Indications Seizures. Combative with hallucinations or paranoia and risk to self or others.

Contraindications Shock. Depressed vital signs or alcohol-related altered level of consciousness. Respiratory depression. Known severe adverse reaction.

Usual Dosages Adults: Seizure: 2.5 mg IV or 5 mg IM or 10 mg buccal or 5 mg intranasal (Repeat x 1 prn). Paramedic: IM, buccal or IN only.

Paediatric: Seizure: < 1year: 2.5 mg buccal 1 year to < 5 years: 5 mg buccal 5 years to < 10 years: 7.5 mg buccal ≥ 10 years: 10 mg buccal or 0.2 mg/Kg intranasal or 0.1 mg/Kg IV/IO (Repeat x 1 prn) Paramedic: buccal or IN only

Pharmacology/Action It affects the activity of a chemical that transmits impulses across nerve synapses called Gamma-AminoButyric Acid (GABA). GABA is an inhibitory neurotransmitter. Midazolam works by increasing the effects of GABA at these receptors.

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Medication Midazolam Solution (contd)

Side effects Respiratory depression, headache, hypotension & drowsiness

Additional information Midazolam IV should be titrated to effect. Ensure oxygen and resuscitation equipment are available prior to administration. No more than two doses by practitioners. Practitioners should take into account the dose administered by carers prior to arrival of practitioner.

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Medication Naloxone

Class Narcotic antagonist

Description Effective in management and reversal of overdoses caused by narcotics or synthetic narcotic agents.

Presentation Ampoules 0.4 mg in 1 mL (400 mcg /1 mL) or pre-loaded syringe

Administration Intravenous (IV) Intramuscular (IM) Subcutaneous (SC) Intraosseous (IO) Intranasal (IN) (CPG: 6.4.22, 4/5.4.22, 5/6.5.2, 4/5/6.7.11)

Indications Inadequate respiration and/or ALoC following known or suspected narcotic overdose.

Contraindications Known severe adverse reaction

Usual Dosages Adult: 0.4 mg (400 mcg) IV/IO (AP) 0.4 mg (400 mcg) IM or SC (P) 0.8 mg (800 mcg) IN (EMT) Repeat after 3 min if indicated to a Max 2 mg

Paediatric: 0.01 mg/Kg (10 mcg/Kg) IV/IO (AP) 0.01 mg/Kg (10 mcg/Kg) IM/SC (P) 0.02 mg/Kg (20 mcg/Kg) IN (EMT) Repeat dose prn to maintain opioid reversal to Max 0.1 mg/Kg or 2 mg

Pharmacology/Action Narcotic antagonist Reverse the respiratory depression and analgesic effect of narcotics

Side effects Acute reversal of narcotic effect ranging from nausea & vomiting to agitation and seizures.

Additional information Use with caution in pregnancy. Administer with caution to patients who have taken large dose of narcotics or are physically dependent. Rapid reversal will precipitate acute withdrawal syndrome. Prepare to deal with aggressive patients.

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Medication Nitrous Oxide 50% and Oxygen 50% (Entonox®)

Class Analgesic

Description Potent analgesic gas contains a mixture of both nitrous oxide and oxygen.

Presentation Cylinder, coloured blue with white and blue triangles on cylinder shoulders Medical gas: 50% Nitrous Oxide & 50% Oxygen

Administration Self-administered Inhalation by demand valve with face-mask or mouthpiece (CPG: 4/5/6.2.6, 5/6.5.1, 4.5.1, 5/6.5.6, 4/5/6.7.5)

Indications Pain relief

Contraindications Altered level of consciousness Chest Injury/Pneumothorax Shock Recent scuba dive Decompression sickness Intestinal obstruction Inhalation Injury Carbon monoxide (CO) poisoning Known severe adverse reaction

Usual Dosages Adult: Self-administered until pain relieved

Paediatric: Self-administered until pain relieved

Pharmacology/Action Analgesic agent gas: - CNS depressant - Pain relief

Side effects Disinhibition Decreased level of consciousness Lightheadedness

Additional information Do not use if patient unable to understand instructions. In cold temperatures warm cylinder and invert to ensure mix of gases. Advanced Paramedics may use discretion with minor chest injuries. Brand name: Entonox®. Has an addictive property. Caution when using Entonox for greater than one hour for Sickle Cell Crisis.

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Medication Oxygen

Class Gas

Description Odourless, tasteless, colourless gas necessary for life.

Presentation D, E or F cylinders, coloured black with white shoulders. CD cylinder; white cylinder Medical gas

Administration Inhalation via: High concentration reservoir (non-rebreather) mask Simple face mask Venturi mask Tracheostomy mask Nasal cannulae Bag Valve Mask (CPG: Oxygen is used extensively throughout the CPGs)

Indications Absent/inadequate ventilation following an acute medical or traumatic event SpO2 < 94% adults and < 96% paediatrics SpO2 < 92% for patients with acute exacerbation of COPD

Contraindications Bleomycin lung injury

Usual Dosages Adult: Cardiac and respiratory arrest or Sickle Cell Crisis; 100% Life threats identified during primary survey; 00%1 until a reliable SpO2 measurement obtained then titrate O2 to achieve SpO2 of 94% - 98% For patients with acute exacerbation of COPD, administer O2 titrate to achieve SpO2 92% or as specified on COPD Oxygen Alert Card All other acute medical and trauma titrate O2 to achieve SpO2 94% -98%

Paediatric: Cardiac and respiratory arrest or Sickle Cell Crisis; 100% Life threats identified during primary survey; 00%1 until a reliable SpO2 measurement obtained then titrate O2 to achieve SpO2 of 96% - 98% All other acute medical and trauma titrate O2 to achieve SpO2 of 96% - 98%

Pharmacology/Action Oxygenation of tissue/organs

Side effects Prolonged use of O2 with chronic COPD patients may lead to reduction in ventilation stimulus.

A written record must be made of what oxygen therapy is given to every patient. Additional information Documentation recording oximetry measurements should state whether the patient is breathing air or a specified dose of supplemental oxygen. Consider humidifier if oxygen therapy for paediatric patients is > 30 minute duration. Caution with paraquat poisoning, administer oxygen if SpO2 < 92% Avoid naked flames, powerful oxidising agent.

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Medication Paracetamol

Class Analgesic and antipyretic

Description Paracetamol is used to reduce pain and body temperature

Presentation Rectal suppository 180 mg and 60 mg Suspension 120 mg in 5 mL or 250 mg in 5 mL 500 mg tablet

Administration Per Rectum (PR) Orally (PO) (CPG: 4/5/6.2.6, 4/5/6.4.24, 4/5/6.7.5, 4/5/6.7.35)

Indications Pyrexia Minor or moderate pain (1 - 6 on pain scale) for adult and paediatric patients

Contraindications Known severe adverse reaction Chronic liver disease < 1 month old

Usual Dosages Adult: 1 g PO

Paediatric: PR (AP) PO (AP, P & EMT) > 1 mth < 1 year - 90 mg PR 20 mg/Kg PO 1-3 years - 180 mg PR 4-8 years - 360 mg PR

Pharmacology/Action Analgesic – central prostaglandin inhibitor. Antipyretic – prevents the hypothalamus from synthesising prostaglandin E, inhibiting the body temperature from rising further.

Side effects None

Long-term side effects Long-term use at high dosage or over dosage can cause liver damage and less frequently renal damage.

Additional information Note: Paracetamol is contained in Paracetamol Suspension and other over-the-counter drugs. Consult with parent/guardian in relation to medication prior to arrival on scene.

For PR use be aware of modesty of patient, should be administered in presence of a 2nd person.

If Paracetamol administered in previous 4 hours, adjust the dose downward by the amount given by other sources resulting in a maximum of 20 mg/Kg.

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Medication Salbutamol

Class Sympathetic agonist

Description Sympathomimetic that is selective for beta-2 adrenergic receptors

Presentation Nebule 2.5 mg in 2.5 mL Nebule 5 mg in 2.5 mL Aerosol inhaler: metered dose 0.1 mg (100 mcg)

Administration Nebuliser (NEB) Inhalation via aerosol inhaler (CPG: 4/5/6.3.3, 4/5/6.3.4, 3.3.4, 5/6.4.15, 4.4.15, 2/3.4.16, 4/5/6.6.10, 4/5/6.7.12, 3.7.12, 5/6.7.31, 4.7.31, 2/3.7.31)

Indications Bronchospasm Exacerbation of COPD Respiratory distress following submersion incident

Contraindications Known severe adverse reaction

Usual Dosages Adult: 5 mg NEB (or 0.1 mg metered aerosol spray x 5) Repeat at 5 min prn (EFRs: 0.1 mg metered aerosol spray x 2)

Paediatric: < 5 yrs - 2.5 mg NEB (or 0.1 mg metered aerosol spray x 3) > 5 yrs - 5 mg NEB (or 0.1 mg metered aerosol spray x 5) Repeat at 5 min prn (EFRs: 0.1 mg metered aerosol spray x 2)

Pharmacology/Action Beta-2 agonist Bronchodilation Relaxation of smooth muscle

Side effects Tachycardia Tremors Tachyarrhythmias High doses may cause hypokalaemia

Additional information It is more efficient to use a volumizer in conjunction with an aerosol inhaler when administering Salbutamol. If an oxygen driven nebuliser is used to administer Salbutamol for a patient with acute exacerbation of COPD it should be limited to 6 minutes maximum.

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Medication Sodium Chloride 0.9% (NaCl)

Class Isotonic crystalloid solution

Description Solution of sodium and chloride, also known as normal saline (NaCl)

Presentation Soft pack for infusion 100 mL, 500 mL & 1,000 mL Ampoules 10 mL

Administration Intravenous (IV) infusion, Intravenous (IV) flush, Intraosseous (IO) Paramedic: maintain infusion once commenced (CPG: Sodium Chloride 0.9% is used extensively throughout the CPGs)

Indications IV/IO fluid for pre-hospital emergency care

Contraindications Known severe adverse reaction

Usual Dosages ADULT Keep vein open (KVO) or medication flush for cardiac arrest prn

Crush injury, Suspension Trauma, PEA or Asystole: 20 mL/Kg IV/IO infusion

Hypothermia: 250 mL IV/IO infusion (warmed to 40oC approx) Repeat to max 1 L

# neck of femur, sepsis: 250 mL IV infusion

Decompression illness, sepsis with poor perfusion; 500 mL IV/IO infusion

Shock from blood loss; 500 mL IV/IO infusion. Repeat in aliquots of 250 mL prn to maintain systolic BP of; 90 – 100 mmHg 120 mmHg (head injury GCS ≤ 8)

Burns; > 25% TBSA and/or 1 hour from time of injury to ED, 1000 mL IV/IO infusion > 10% TBSA consider 500 mL IV/IO infusion

Adrenal insufficiency, Glycaemic emergency, Heat-related Emergency, Sickle Cell Crisis; 1,000 mL IV/IO infusion

Anaphylaxis, post partum haemorrhage; 1,000 mL IV/IO infusion, repeat x one prn

Post-resuscitation care: 1,000 mL IV/IO infusion (at 4oC approx). If persistent hypotension maintain Sys BP > 90 mmHg

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Medication Sodium Chloride 0.9% (NaCl) (contd)

PAEDIATRIC Keep vein open (KVO) or medication flush for cardiac arrest prn

Glycaemic emergency, Neonatal resuscitation, Sickle Cell Crisis: 10 mL/Kg IV/IO infusion

Hypothermia: 10 mL/Kg IV/IO infusion (warmed to 40oC approx). Repeat prn x 1

Haemorrhagic shock; 10 mL/Kg IV/IO, repeat prn if signs of inadequate perfusion

Anaphylaxis; 20 mL/Kg IV/IO infusion, repeat x one prn

Adrenal insufficiency, Crush injury, Septic shock, Suspension Trauma, Symptomatic Bradycardia, Asysotol/PEA: 20 mL/Kg IV/IO infusion

Post-resuscitation care: 20 mL/Kg IV/IO infusion if persistent poor perfusion

Burns: > 10% TBSA and/or > 1 hour from time of injury to ED: 5 – 10 years: 250 mL IV/IO > 10 years: 500 mL IV/IO

Pharmacology/Action Isotonic crystalloid solution Fluid replacement

Side effects Excessive volume replacement may lead to heart failure

Additional information NaCl is the IV/IO fluid of choice for pre-hospital emergency care

For KVO use 500 mL pack only

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Medication Ticagrelor

Class Platelet aggregation inhibitor

Description An inhibitor of platelet function

Presentation 90 mg tablets

Administration Orally (PO) (CPG: 5/6.4.10)

Indications Identification of ST Elevation Myocardial Infarction (STEMI) if transporting to PPCI centre

Contraindications Hypersensitivity to the active substance (Ticagrelor) or to any of the excipients Active pathological bleeding History of intracranial haemorrhage Moderate to severe hepatic impairment

Usual Dosages Adult: Loading dose 180 mg PO

Paediatric: Not indicated

Pharmacology/Action Ticagrelor is a selective adenosine diphosphate (ADP) receptor antagonist acting on the P2Y12 ADP-receptor that can prevent ADP-mediated platelet activation and aggregation. Ticagrelor is orally active, and reversibly interacts with the platelet P2Y12 ADP-receptor. Ticagrelor does not interact with the ADP binding site itself, but interacts with platelet P2Y12 ADP-receptor to prevent signal transduction.

Side effects Common: Dyspnoea, epistaxis, gastrointestinal haemorrhage, subcutaneous or dermal bleeding, bruising and procedural site haemorrhage.

Other undesirable effects include intracranial bleeding, elevations of serum creatinine and uric acid levels. Consult SmPC for a full list of undesirable effects.

Additional information Special authorisation: Advanced paramedics and paramedics are authorised to administer Ticagrelor 180 mg PO following identification of STEMI and medical practitioner instruction. If a patient has been loaded with an anti-platelet medication (other than aspirin), prior to the arrival of the practitioner, the patient should not have Ticagrelor administered.

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APPENDIX 2 MEDICATIONS & SKILLS MATRIX NEW FOR 2014

CLINICAL LEVEL CFR-C CFR-A FAR/OFA EFR EMT P AP

Burns care P P P P P Soft tissue injury P P P P P SpO2 monitoring P Move and secure a patient to a P paediatric board Ibuprofen PO P Salbutamol Nebule P Subcutaneous injection P P Naloxone IN P P P Pain assessment P P P Haemostatic agent P P P End Tidal CO2 monitoring P Hydrocortisone IM P Ipratropium Bromide Nebule P CPAP / BiPAP P P Naloxone SC P P Nasal pack P P Ticagrelor P P Treat and referral P P Tranexamic Acid P

CARE MANAGEMENT INCLUDING THE ADMINISTRATION OF MEDICATIONS AS PER LEVEL OF TRAINING AND DIVISION ON THE PHECC REGISTER AND RESPONDER LEVELS.

Pre-Hospital responders and practitioners shall only provide care management including medication administration for which they have received specific training. Practioners must be privileged by a licensed CPG provider to administer specific medications and perform specific clinical interventions. KEY

P = Authorised under PHECC CPGs

URMPIO = Authorised under PHECC CPGs under registered medical practitioner’s instructions only

APO = Authorised under PHECC CPGs to assist practitioners only (when applied to EMT, to assist Paramedic or higher clinical levels)

SA = Authorised subject to special authorisation as per CPG

BTEC = Authorised subject to Basic Tactical Emergency Care rules

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APPENDIX 2 MEDICATIONS & SKILLS MATRIX MEDICATIONS

CLINICAL LEVEL CFR-C CFR-A FAR/OFA EFR EMT P AP

Aspirin PO P P P P P P P Oxygen P P P P P Glucose Gel Buccal P P P P GTN SL PSA P P P Salbutamol Aerosol PSA P P P Epinephrine (1:1,000) auto injector P P P Glucagon IM P P P Nitrous oxide & Oxygen (Entonox©) P P P Naloxone IN P P P Paracetamol PO P P P Ibuprofen PO P P P Salbutamol nebule P P P Morphine IM URMPIO URMPIO PSA Clopidogrel PO P P Epinephrine (1: 1,000) IM P P Hydrocortisone IM P P Ipratropium Bromide Nebule P P Midazolam IM/Buccal/IN P P Naloxone IM/SC P P Ticagrelor P P Dextrose 10% IV PSA P Hartmann’s Solution IV/IO PSA P Sodium Chloride 0.9% IV/IO PSA P Amiodarone IV/IO P Atropine IV/IO P Benzylpenicillin IM/IV/IO P Cyclizine IV P Diazepam IV/PR P Epinephrine (1:10,000) IV/IO P Fentanyl IN P Furosemide IV/IM P Hydrocortisone IV P Lorazepam PO P Magnesium Sulphate IV P Midazolam IV P

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APPENDIX 2 MEDICATIONS & SKILLS MATRIX MEDICATIONS (contd)

CLINICAL LEVEL CFR-C CFR-A FAR/OFA EFR EMT P AP

Morphine IV/PO P Naloxone IV/IO P Nifedipine PO P Ondansetron IV P Paracetamol PR P Sodium Bicarbonate IV/ IO P Syntometrine IM P Tranexamic Acid P Enoxaparin IV/SC PSA Lidocaine IV PSA Tenecteplase IV PSA

AIRWAY & BREATHING MANAGEMENT

CLINICAL LEVEL CFR-C CFR-A FAR/OFA EFR EMT P AP

FBAO management P P P P P P P Head tilt chin lift P P P P P P P Pocket mask P P P P P P P Recovery position P P P P P P P Non rebreather mask P P P P P OPA P P P P P Suctioning P P P P P Venturi mask P P P P P SpO2 monitoring PSA P P P P Jaw Thrust P P P P BVM P PSA P P P NPA BTEC BTEC P P Nasal cannula P P P P Supraglottic airway adult (uncuffed) P P P P Oxygen humidification P P P Supraglottic airway adult (cuffed) PSA P P CPAP / BiPAP P P Non-invasive ventilation device P P Peak Expiratory Flow P P

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APPENDIX 2 MEDICATIONS & SKILLS MATRIX AIRWAY & BREATHING MANAGEMENT (contd) CLINICAL LEVEL CFR-C CFR-A FAR/OFA EFR EMT P AP

End Tidal CO2 monitoring P P Supraglottic airway paediatric PSA P Endotracheal intubation P Laryngoscopy and Magill forceps P Needle cricothyrotomy P Needle thoracocentesis P

CARDIAC

CLINICAL LEVEL CFR-C CFR-A FAR/OFA EFR EMT P AP

AED adult & paediatric P P P P P P P CPR adult, child & infant P P P P P P P Recognise death and resuscitation P P P P P P P not indicated Targeted temperature management PSA P P P CPR newly born P P P ECG monitoring (lead II) P P P Mechanical assist CPR device P P P 12 lead ECG P P Cease resuscitation - adult P P Manual defibrillation P P

HAEMORRHAGE CONTROL

CLINICAL LEVEL CFR-C CFR-A FAR/OFA EFR EMT P AP

Direct pressure P P P P P Nose bleed P P P P P Haemostatic agent P P P Tourniquet use BTEC BTEC P P Nasal pack P P Pressure points P P

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APPENDIX 2 MEDICATIONS & SKILLS MATRIX MEDICATION ADMINISTRATION

CLINICAL LEVEL CFR-C CFR-A FAR/OFA EFR EMT P AP

Oral P P P P P P P Buccal route P P P P Per aerosol (inhaler) + spacer PSA P P P Sublingual PSA P P P Intramuscular injection P P P Intranasal P P P Per nebuliser P P P Subcutaneous injection P P P IV & IO Infusion maintenance PSA P Infusion calculations P Intraosseous injection/infusion P Intravenous injection/infusion P Per rectum P

TRAUMA

CLINICAL LEVEL CFR-C CFR-A FAR/OFA EFR EMT P AP

Burns care P P P P P Cervical spine manual stabilisation P P P P P Application of a sling P P P P P Soft tissue injury P P P P P Cervical collar application P P P P Helmet stabilisation/removal P P P P Splinting device application to upper P P P P limb Move and secure patient to a long PSA P P P board Rapid Extraction PSA P P P Log roll APO P P P Move patient with a carrying sheet APO P P P Move patient with an orthopaedic APO P P P stretcher Splinting device application to lower APO P P P limb Secure and move a patient with an APO APO P P extrication device

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APPENDIX 2 MEDICATIONS & SKILLS MATRIX TRAUMA (contd)

CLINICAL LEVEL CFR-C CFR-A FAR/OFA EFR EMT P AP

Pelvic Splinting device BTEC P P P Move and secure patient into a BTEC P P P vacuum mattress Active re-warming P P P Move and secure a patient to a P P P paediatric board Traction splint application APO P P Spinal Injury Decision P P Taser gun barb removal P P Reduction dislocated patella P

OTHER

CLINICAL LEVEL CFR-C CFR-A FAR/OFA EFR EMT P AP

Assist in the normal delivery of a APO P P P baby De-escalation and breakaway skills P P P Glucometry P P P Broselow tape P P Delivery Complications P P External massage of uterus P P Intraosseous cannulation P Intravenous cannulation P Urinary catheterisation P

PATIENT ASSESSMENT

CLINICAL LEVEL CFR-C CFR-A FAR/OFA EFR EMT P AP

Assess responsiveness P P P P P P P Check breathing P P P P P P P FAST assessment P P P P P P P Capillary refill P P P P P AVPU P P P P P Breathing & pulse rate P P P P P

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APPENDIX 2 MEDICATIONS & SKILLS MATRIX PATIENT ASSESSMENT (contd)

CLINICAL LEVEL CFR-C CFR-A FAR/OFA EFR EMT P AP

Primary survey P P P P P SAMPLE history P P P P P Secondary survey P P P P P CSM assessment P P P P Rule of Nines P P P P Blood pressure PSA P P P Assess pupils P P P Capacity evaluation P P P Do Not Attempt Resuscitation P P P Paediatric Assessment Triangle P P P Pain assessment P P P Patient Clinical Status P P P Pre-hospital Early Warning Score P P P Pulse check (cardiac arrest) PSA P P P Temperature OC P P P Triage sieve P P P Chest auscultation P P GCS P P Treat and referral P P Triage sort P P

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APPENDIX 3 CRITICAL INCIDENT STRESS MANAGEMENT

Your Psychological Well-Being

As a Practitioner it is extremely important for your psychological well-being that you do not expect to save every critically ill or injured patient that you treat. For a patient who is not in hospital, whether they survive a cardiac arrest or multiple trauma depends on a number of factors including any other medical condition the patient has. Your aim should be to perform your interventions well and to administer the appropriate medications within your scope of practice. However sometimes you may encounter a situation which is highly stressful for you, giving rise to Critical Incident Stress (CIS). A critical incident is an incident or event which may overwhelm or threaten to overwhelm our normal coping responses. As a result of this we can experience CIS.

SYMPTOMS OF CIS INCLUDE SOME OR ALL OF THE FOLLOWING:

Examples of physical symptoms: Examples of psychological symptoms: • Feeling hot and flushed, sweating a lot • Feeling overwhelmed • Dry mouth, churning stomach • Loss of motivation • Diarrhoea and digestive problems • Dreading going to work • Needing to urinate often • Becoming withdrawn • Muscle tension • Racing thoughts • Restlessness, tiredness, sleep difficulties, headaches • Confusion • Increased drinking or smoking • Not looking after yourself properly • Overeating, or loss of appetite • Difficulty making decisions • Loss of interest in sex • Poor concentration • Racing heart, breathlessness and rapid breathing • Poor memory • Anger • Anxiety • Depression

Post-Traumatic Stress Reactions

Normally the symptoms of Critical Incident Stress subside within a few weeks or less. Sometimes however, they may persist and develop into a post-traumatic stress reaction and you may also experience emotional reactions.

Anger at the injustice and senselessness of it all.

Sadness and depression caused by an awareness of how little can be done for people who are severely injured and dying, sense of a shortened future, poor concentration, not being able to remember things as well as before.

Guilt caused by believing that you should have been able to do more or that you could have acted differently.

Fear of ‘breaking down’ or ‘losing control’, not having done all you could have done, being blamed for something or a similar event happening to you or your loved ones.

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Avoiding the scene of the trauma or anything that reminds you of it.

Intrusive thoughts in the form of memories or flashbacks which cause distress and the same emotions as you felt at the time.

Irritability outbursts of anger, being easily startled and constantly being on guard for threats.

Feeling numb leading to a loss of your normal range of feelings, for example, being unable to show affection, feeling detached from others.

EXPERIENCING SIGNS OF EXCESSIVE STRESS If the range of physical, emotional and behavioural signs and symptoms already mentioned do not reduce over time (for example, after two weeks), it is important that you get support and help.

Where to find help?

Your own CPG approved organisation will have a CISM support network or system. We recommend that you contact them for help and advice. (i.e. your peer support worker/coordinator/staff support officer).

• For a self-help guide, please go to www.cismnetworkireland.ie • NAS CISM/ CISM Network published a booklet called ‘Critical Incident Stress Management for Emergency Personnel’. It can be purchased by emailing [email protected] • The NAS CISM committee in partnership with PHECC developed an eLearning CISM Stress Awareness Training (SAT) module. It can be accessed by all PHECC registered practitioners using their PHECC eLearning username and password. In due course PHECC will launch a CISM SAT module for non-PHECC registered personnel. • See a health professional who specialises in traumatic stress.

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APPENDIX 4 CPG UPDATES FOR PARAMEDICS

CPG updates 2014

For administrative purposes the numbering system on some CPGs has been changed.

The paediatric age range has been extended to reflect the new national paediatric age ≤( 15 years), as outlined by The National Clinical Programme for Paediatrics and Neonatology.

CPGs that have content changes are outlined below.

Updated CPGs from the 2012 version.

CPGs The principal differences are Theory Skills

CPG 4/5/6.2.1 EMTs, who have completed the BTEC course, may be privileged by a . P x Primary Survey Medical – licensed CPG provider to insert an NPA following appropriate training. Adult CPG 4/5/6.2.2 EMTs, who have completed the BTEC course, may be privileged by a P x Primary Survey Trauma – licensed CPG provider to insert an NPA following appropriate training. Adult

CPG 5/6.2.5 ECG & SpO2 monitoring inserted on multi-system trauma arm. P x Secondary Survey Trauma – Adult Add ‘consider repeat primary survey’. P x CPG 4/5/6.2.6 Delete ‘Minor pain (2 to 3 on pain scale)’ replace with ‘Mild pain P x Pain Management – Adult (1 to 3 on pain scale)’

Change Moderate pain to ‘4 to 6 on the pain scale’ P x

Change Severe pain to ‘≥ 7 on the pain scale’ P x

Add Fentanyl IN for advanced paramedic practice P x

Add Ibuprofen PO for EMT practice P x CPG 5/6.3.1 The age range from 8 years has been replaced by standard adult range. P x Advanced Airway Management – Adult It is now explicit that following two unsuccessful attempts at intubation P x an AP may attempt insertion of a supraglottic airway. CPG 4/5/6.3.2 This CPG replaces Inadequate Respirations – Adult (5/6.3.2 and 4.3.2) P x Inadequate Ventilations – incorporating all three practitioner levels in one CPG. Adult This CPG outlines generic care for all patients with inadequate P x ventilation and then offers pathways for specific clinical issues.

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CPGs The principal differences are Theory Skills

CPG 4/5/6.3.3 This CPG incorporates all three practitioner levels in one CPG replacing P x Exacerbation of COPD 4.3.3 at EMT level.

Peak expiratory flow measurement is now within the scope of practice P P for paramedics.

Salbutamol Neb is now within the scope of practice for EMTs. P x

Ipratropium bromide Neb is now within the scope of practice for P P paramedics. CPG 5/6.4.10 Thrombolysis has been removed from the scope of practice for advanced P x Acute Coronary Syndrome paramedics.

Ticagrelor is now within the scope of practice for paramedics and P P advanced paramedics.

The dose for Clopidogrel has been reduced from 600 mg to 300 mg. P x

The indication for Clopidogrel has been changed; it is now indicated for P x patients with confirmed STEMI who are not transported to a PPCI centre. CPG 4/5/6.4.11 The dose of Atropine has been increased from 0.5 mg to 0.6 mg. P x Symptomatic Bradycardia – Adult Add ‘NaCL infusion 250 mL (repeat by one)’ P x

Insert information box; ‘Titrate Atropine to effect (HR > 60)’ P x CPG 4/5/6.4.17 Digital pressure has been increased to 15 minutes. P x Epistaxis The insertion of a proprietary nasal pack is now within the scope of P P practice for paramedics and advanced paramedics. CPG 5/6.4.21 Paramedic has been included in this CPG. P x Hypothermia Warmed O2 has been removed. P x

Mild hypothermia is now defined as 34 – 35.9oC. P x

Moderate hypothermia is now defined as 30 – 33.9oC. P x

Paediatric dose for NaCl has been reduced from 20 mL/Kg to 10 mL/Kg. P x

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CPGs The principal differences are Theory Skills

CPG 6.4.22 The methods of introduction of a poison have been removed. P x Poisons – Adult Naloxone has been added to this CPG for opiate induced poison. P x

Naloxone IN is now within the scope of practice for EMTs and P x paramedics.

The absolute contraindication for O2 has been removed following P x paraquat poisoning. CPG 5/6.4.23 Magnesium sulphate may be considered by advanced paramedics to P x Seizure/Convulsion – Adult manage a pre-eclampsia patient who is seizing. CPG 4/5/6.4.24 This CPG replaces Septic Shock - Adult. P x Sepsis – Adult It authorises the administration of Paracetamol for pyrexic patients. P x

It authorises the administration, by advanced paramedics, of P x Benzylpenicillin for severe sepsis.

Advanced paramedics may consider additional aliquots of NaCl to P x maintain systolic BP > 100 mmHg. CPG 4/5/6.6.1 Add ‘Caution with hypothermia’ P x Burns – Adult CPG 4/5/6.6.3 This CPG has been updated to reflect the importance of managing P x External Haemorrhage – catastrophic haemorrhage immediately. Adult Dressings impregnated with haemostatic agents are now within the P P scope of practice for EMTs, paramedics and advanced paramedics.

EMTs, who have completed the BTEC course, may be privileged by a P x licensed CPG provider to apply a tourniquet.

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CPGs The principal differences are Theory Skills

CPG 5/6.6.5 LoC history has been replaced with ‘consider spinal injury’ P x Head Injury – Adult Collar and long board have been replaced with ‘see Spinal injury CPG’ to P x avoid repetition.

A ‘GCS of < 12’ has been replaced with a ‘GCS of ≤ 12’ P x

An emphasis has been placed on minimising Intra Cranial Pressure; using P x pain management, control of nausea & vomiting, 10o upward head tilt and ensuring that the collar is not too tight.

‘Maintain SBP > 120 mmHg’ has been replaced with ‘avoid hypotension’ P x

‘Transport to most appropriate ED according to local protocol’ has been P x deleted CPG 4/5/6.6.7 Fractured neck of femur has been included. P x Limb Injury – Adult With a fractured neck of femur, if the transport time to ED is > 20 P x minutes, ALS should be requested.

With a fractured neck of femur advanced paramedics should consider P x NaCl infusion. CPG 5/6.6.8 This CPG has been renamed from ‘Shock from Blood Loss – Adult’. P x Shock from Blood Loss (trauma) – Adult Add; with polytrauma consider application of a pelvic splint. P x

Change ‘Trauma’ to ‘Suspected significant internal/ external P x haemorrhage’

Tranexamic acid is now within the scope of practice for advanced P x paramedics. CPG 4/5/6.6.10 Salbutamol is now within the scope of practice for EMTs. P x Submersion Incident CPG 4/5/6.7.4 The estimated weight formula has been updated; P x Secondary Survey – Neonate = 3.5 Kg Paediatric Six months = 6 Kg One to five years = (age x 2) + 8 Kg Greater than 5 years = (age x 3) + 7 Kg

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APPENDIX 4 CPG UPDATES FOR PARAMEDICS

CPGs The principal differences are Theory Skills CPG 4/5/6.7.5 Pain assessment recommendations; P P Pain Management – < 5 years use FLACC scale Paediatric 5 – 7 years use Wong Baker scale ≥ 8 years use analogue pain scale

Delete ‘Minor pain (2 to 3 on pain scale)’ replace with ‘Mild pain (1 to 3 P x on pain scale)’

Change Moderate pain to ‘4 to 6 on the pain scale’ P x

Change Severe pain to ‘≥ 7 on the pain scale’ P x

Fentanyl IN is now within the scope of practice for advanced paramedics. P x

Ibuprofen PO is now within the scope of practice for EMTs. P x CPG 4/5/6.7.11 This CPG replaces Inadequate Respirations – Paediatric (5/6.7.5 and P x Inadequate Ventilations – 4.7.5) incorporating all three practitioner levels in one CPG. Paediatric This CPG outlines generic care for all patients with inadequate P x ventilation and then offers pathways for specific clinical issues.

Naloxone IN is now within the scope of practice for EMTs, paramedics P P and advanced paramedics.

CPG 4/5/6.7.24 ‘The routine ventilations’ has been changed to ‘ventilations if hypoxic’. P x Symptomatic Bradycardia – Paediatric Unresponsive has been added as a criteria for CPR P x

Consider advanced airway management if prolonged CPR has been P x removed. CPG 5/6.7.32 The dose of NaCl has been reduced from 20 mL/Kg to 10 mL/Kg. P x Glycaemic Emergency – Paediatric CPG 5/6.7.33 The dose of Midazolam buccal has been changed from weight based to P P Seizure/ Convulsion – age based. Paediatric CPG 4/5/6.7.50 This CPG has been updated to reflect the importance of managing P x External Haemorrhage – catastrophic haemorrhage immediately. Paediatric Dressings impregnated with haemostatic agents are now within the P P scope of practice for EMTs, paramedics and advanced paramedics.

EMTs, who have completed the BTEC course, may be privileged by a P x licensed CPG provider to apply a tourniquet.

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CPGs The principal differences are Theory Skills

CPG 4/5/6.7.53 Add ‘Caution with hypothermia’ P x Burns – Paediatric 4/5/6.8.1 Add ‘ambulance loading point’ P x Major Emergency – First Practitioners on site Add ‘On site co-ordination centre’ P x 4/5/6.8.2 Add information box ‘Controller of Operations may be other than P x Major Emergency – ambulance or fire officers, depending on nature of emergency’ Operational Control

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New CPGs

New CPGs The new skills and medications incorporated in the CPG are: Theory Skills

CPG 4/5/6.3.4 This CPG outlines the care for a patient with an acute asthma episode. P x Asthma – Adult CPG 5/6.3.5 This CPG outlines the care for a patient with an acute pulmonary P P Acute Pulmonary Oedema oedema episode. CPG 5/6.4.12 This CPG outlines the care for a patient with a tachycardia episode. P x Tachycardia – Adult CPG 5/6.4.13 This CPG outlines the care for a patient with an adrenal crisis. P P Adrenal Insufficiency – Adult CPG 5/6.4.25 This CPG outlines the care for a patient with non traumatic blood loss. P x Shock from Blood Loss (non-trauma) – Adult CPG 4/5/6.4.27 This CPG outlines the care for a patient with a sickle cell crisis. P x Sickle Cell Crisis – Adult CPG 4/5/6.6.4 This CPG outlines, in particular, the correct posture for patients following P x Harness Induced harness induced suspension trauma. Suspension Trauma CPG 4/5/6.6.6 This CPG outlines the care for a patient with a heat-related emergency. P x Heat Related Emergency – Adult CPG 5.7.10 This CPG outlines the advanced airway management for a paediatric P x Advanced Airway Manage- patient ≥ 8 years old. ment – Paediatric (≥ 8 years) CPG 4/5/6.7.12 This CPG outlines the care for a paediatric patient with an acute asthma P x Asthma – Paediatric episode. CPG 5/6.7.30 This CPG outlines the care for a paediatric patient with an adrenal crisis. P P Adrenal Insufficiency – Paediatric CPG 4/5/6.7.35 This CPG outlines the care for a paediatric patient with a pyrexia P x Pyrexia – Paediatric episode. CPG 4/5/6.7.36 This CPG outlines the care for a paediatric patient with a sickle cell crisis. P x Sickle Cell Crisis – Paediatric CPG 5/6.9.1 This CPG outlines the inclusion process to select patients for a clinical P x Clinical Care Pathway care pathway other than ED care. Decision – Treat & Referral

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New CPGs The new skills and medications incorporated in the CPG are: Theory Skills

CPG 5/6.9.2 This CPG outlines the exclusion process to select patients following a P x Hypoglycaemia – hypoglycaemic event for a clinical care pathway other than ED care. Treat & Referral CPG 5/6.9.3 This CPG outlines the exclusion process to select patients following an P x Isolated Seizure – Treat & isolated seizure for a clinical care pathway other than ED care. Referral

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APPENDIX 5 PRE-HOSPITAL DEFIBRILLATION POSITION PAPER

Defibrillation is a lifesaving intervention for victims of sudden cardiac arrest (SCA). Defibrillation in isolation is unlikely to reverse SCA unless it is integrated into the chain of survival. The chain of survival should not be regarded as a linear process with each link as a separate entity but once commenced with ‘early access’ the other links, other than ‘post return of spontaneous circulation (ROSC) care’, should be operated in parallel subject to the number of people and clinical skills available.

Cardiac arrest management process

ILCOR guidelines 2010 identified that without ongoing CPR, survival with good neurological function from SCA is highly unlikely. Defibrillators in AED mode can take up to 30 seconds between analysing and charging during which time no CPR is typically being performed. The position below is outlined to ensure maximum resuscitation efficiency and safety.

Position 1. Defibrillation mode 1.1 Advanced paramedics, and health care professionals whose scope of practice permits, should use defibrillators in manual mode for all age groups. 1.2 Paramedics may consider using defibrillators in manual mode for all age groups. 1.3 EMTs and responders shall use defibrillators in AED mode for all age groups.

2. Hands off time (time when chest compressions are stopped) 2.1 Minimise hands off time, absolute maximum 10 seconds. 2.2 Rhythm and/or pulse checks in manual mode should take no more than 5 to 10 seconds and CPR should be recommenced immediately. 2.3 When defibrillators are charging CPR should be ongoing and only stopped for the time it takes to press the defibrillation button and recommenced immediately without reference to rhythm or pulse checks. 2.4 It is necessary to stop CPR to enable some AEDs to analyse the rhythm. Unfortunately this time frame is not standard with all AEDs. As soon as the analysing phase is completed and the charging phase has begun CPR should be recommenced.

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3 Energy 3.1 Biphasic defibrillation is the method of choice. 3.2 Biphasic truncated exponential (BTE) waveform energy commencing at 150 to 200 joules shall be used. 3.3 If unsuccessful the energy on second and subsequent shocks shall be as per manufacturer of defibrillator instructions. 3.4 Monophasic defibrillators currently in use, although not as effective as biphasic defibrillators, may continue to be used until they reach the end of their lifespan.

4 Safety 4.1 For the short number of seconds while a patient is being defibrillated no person should be in contact with the patient. 4.2 The person pressing the defibrillation button is responsible for defibrillation safety. 4.3 Defibrillation pads should be used as opposed to defibrillation paddles for pre-hospital defibrillation.

5 Defibrillation pad placement 5.1 The right defibrillation pad should be placed mid clavicular directly under the right clavicle. 5.2 The left defibrillation pad should be placed mid-axillary with the top border directly under the left nipple. 5.3 If a pacemaker or Implantable Cardioverter Defibrillator (ICD) is fitted, defibrillator pads should be placed at least 8 cm away from these devices. This may result in anterior and posterior pad placement which is acceptable.

6 Paediatric defibrillation 6.1 Paediatric defibrillation refers to patients less than 8 years of age. 6.2 Manual defibrillator energy shall commence and continue with 4 joules/Kg. 6.3 AEDs should use paediatric energy attenuator systems. 6.4 If a paediatric energy attenuator system is not available an adult AED may be used. 6.5 It is extremely unlikely to ever have to defibrillate a child less than 1 year old. Nevertheless, if this were to occur the approach would be the same as for a child over the age of 1. The only likely difference being, the need to place the defibrillation pads anterior and posterior, because of the infant’s small size.

7 Implantable Cardioverter Defibrillator (ICD) 7.1 If an Implantable Cardioverter Defibrillator (ICD) is fitted inhe t patient, treat as per CPG. It is safe to touch a patient with an ICD fitted even if it is firing.

8 Cardioversion 8.1 Advanced paramedics are authorised to use synchronised cardioversion for unresponsive patients with a tachycardia greater than 150.

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Guide ice line ct s ra P l a c P i n

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Published by: Pre-Hospital Emergency Care Council Abbey Moat House, Abbey Street, Naas, Co Kildare, Ireland. Phone: + 353 (0)45 882042 Fax: + 353 (0)45 882089 Email: [email protected] Web: www.phecc.ie Paramedic